Baroness Finlay of Llandaff: My Lords, I beg to move that this Bill be now read a second time.
	I bring this Bill to you 40 years since St Christopher's Hospice opened, and 20 years after the specialty of palliative medicine was officially recognised. What does my Bill do? It lays an obligation on all health service commissioners and providers in England and Wales to work towards ensuring that specialist palliative care services are available for terminally ill people with complex needs and that generalist services can deliver care to meet the ordinary general palliative care needs of patients in the healthcare system as a whole. Such care should be available wherever the patient is. To that end, the Bill requires the development of positive palliative care strategies and annual reports on their achievement.
	This is nothing new. Between 1987 and 1999, the Department of Health issued at least eight circulars or executive letters exhorting health authorities to develop palliative care strategies, but co-ordinated strategies have not happened across the board in 20 years. I have contacted all 10 strategic health authorities in England, but I have received very varying responses to my request for their strategies, drawing a blank on four of them. It is hardly surprising that the voluntary sector finds it difficult to plan and provide in partnership with the NHS.
	What is palliative care and why is it defined as it is in the Bill? Palliative care provides care for patients with advanced, progressive, incurable illness to live as well as possible until they die of their disease. That covers advanced disease of any diagnosis, not just cancers, and it is not confined to only the last days, weeks or months of life. The definition in my Bill is taken from the guidance of the National Institute for Clinical Excellence in 2004 on improving supportive and palliative care for patients with cancer. It is equally applicable, however, to patients with other illnesses and to all ages, and it has been nationally accepted as the working definition. It states:
	"Palliative care is the active holistic care of patients with advanced progressive illness. Management of pain and other symptoms and provision of psychological, social and spiritual support is paramount".
	Note that word "holistic". It means that palliative care concerns the whole patient, not just a collection of symptoms. The NICE guidance was written to guide commissioning, based on evidence including costing data, and it is realistic. It recognises that in many medical conditions physical, psychosocial and spiritual factors are inextricably linked, so that it is necessary to look at the whole patient to be able to diagnose the real problem and plan the best management and treatment, often in conjunction with services such as oncology and surgery, which focus on disease control.
	The noble Baroness, Lady Jay, sent me her apologies that she could not participate today. When she was a Minister at the Department of Health she said:
	"The NHS has much to learn from the example of voluntary hospices, who promote both the physical and psychological well being of patients".
	She went on to say:
	"Developing effective symptom control, openness, respect of the patient's own wishes and the needs and care for the family are the cornerstones of palliative care".
	Indeed they are.
	The NICE guidance states:
	"Many aspects of palliative care are also applicable earlier in the course of the illness in conjunction with other treatments".
	That is particularly important, because it is here in the UK that clinical services have recognised that palliative care may be needed shortly after the time of diagnosis and, as I have said in previous debates, it is not simply a "death-bed science". It helps all those with advanced, progressive, incurable illness to live as well as possible. For that reason, it is so important, and for that reason it has been a catalyst in driving up standards in many other branches of healthcare.
	Recently, we had a debate about measuring the effectiveness of palliative care services that aim to relieve distress. There is much that can be measured. Since 1996, a national minimum data set has been developed and is being modified to meet the needs of the modern NHS. Validated tools are in routine use to monitor patient outcomes in all domains. The UK leads the world in producing those measures. They capture what is important to patients and families and help services to evaluate and audit their care. It is callous to suggest that such data should be ignored just because such assessment is difficult.
	Palliative care does not get it right 100 per cent of the time, but neither does any other specialty. Could anyone realistically claim that diabetic care achieves 100 per cent effective control with no complications, or that every patient with hypertension has perfect blood pressure control? Such an attitude is unrealistic and allows neither for the vagaries of disease nor for the circumstances of the individual. It is through audit and reflective practice that lessons are learnt when things do not go right. It is through research that we improve care and discover better treatments. That is why my Bill requires that research should be facilitated, not hindered.
	The relief of physical symptoms is the bedrock of the discipline and the focus of much research. That science has moved forward in leaps and bounds in recent years. This is a young specialty, with a rapidly developing evidence base. Year on year, there is a marked increase in scientific publications. A search for "palliative care" on PubMed brings more than 27,000 articles from peer-reviewed journals, with over one third of those published in 2006 alone. Research in palliative care, helped by this Government's important initiatives, is improving the care of patients. For example, confusion with opioids and adverse drug effects are now rare as adjuvant analgesics have come along and techniques such as opioid rotation developed. Terminally ill patients are willing to participate in research, even though randomised control trials pose a challenge at the end of life. Some outcomes are as yet difficult to measure, but is that a just reason to abandon looking for them?
	Symptom control is a science. Morphine and other drugs given appropriately at the end of life do not shorten life. I shall repeat that: morphine given appropriately does not shorten life, contrary to the misinformation on Radio 4 this morning. Morphine may even prolong life by ensuring that patients are comfortable and not exhausted through intractable symptoms.
	Research is not confined to symptom control, but encompasses much wider aspects of good care. Palliative care is one of the few specialties that are actively exploring the existential issues of loss of dignity and personal control, and support for the family. It has been championing privacy, has been at the forefront of ensuring that patients are listened to, that patients' concerns are addressed and that they are given true choices over what can be done for them, including being asked where they would liked to be cared for and where they would like to die. Many aspects of this work are undertaken by specialist nurses and my Bill is strongly supported by the Royal College of Nursing.
	Specialist palliative care is teaching the rest of healthcare staff what to do and how to do it better, aiming to raise the general level of palliative care provision across the health service. Specialist palliative care has never claimed that it should or could look after all patients who are dying. The specialist services are there to look after difficult and complex cases, to drive up standards, to research and above all to teach. Every patient encounter is a potential teaching opportunity and specialist palliative care teams view the education of their fellow professionals as a core duty.
	The General Medical Council states that it welcomes the opportunity provided by this Bill for consideration of how palliative care services should be provided. It states that it feels that the debate is timely, because it plans,
	"to review over the coming months the standards expected of medical graduates in order to gain entry to the medical profession and ... can ensure that the themes of this debate are included in this review".
	That is a major step forward. Licensing will require that those medical graduates know something about palliative care.
	Specialist palliative care is the only healthcare service which has been developed outside the NHS, which is principally provided outside the NHS, and yet on which the NHS is very dependent. It has completely changed patient care. I do not make that claim lightly. Specialist palliative care services have been teaching communication skills, have challenged the way that pain relief and other symptoms are managed and have turned many practices on their head. People now, rightly, expect to receive analgesics such as morphine in adequate dose. Families expect adequate information when someone is very sick and dying, but, sadly, those standards are not embedded in all general services. Indeed, the recent Healthcare Commission report revealed that more than half of the complaints about hospitals concerned care around the time of a patient's death, and a recurring theme in complaints was poor communication between staff and patients and their family.
	The duty to provide palliative care to such an extent as is necessary to reach a patient's reasonable requirements is precisely because care must be underpinned by ensuring that respect for the person, their dignity and privacy are part of all aspects of care. The Bill stipulates "reasonable requirements" because need and demand are not synonymous. Services are not limitless—far from it—and the principle of justice dictates that each person should have the best care within the resources available and that there must be an equitable distribution of resources. "I want" does not mean "I get", but needs that are properly assessed and identified must and should be met.
	The Bill is supported by the National Council for Palliative Care and its partner organisations Help the Hospices, Marie Curie Cancer Care and Sue Ryder Care. The national council has been working with the Department of Health for many years and has undertaken a population-based needs assessment for palliative care in England and an in-depth review in Wales. It has been collecting minimum data on services and has estimated that 300,000 people per annum could benefit from specialist palliative care, but are not referred because their clinical service does not have links to such a service.
	I bring this Bill before your Lordships more in sorrow than in anger. For more than 20 years, the whole of my consultant career, there have been executive letters to health authorities and to their successors instructing them to develop strategies at a local level for equitable care. In 2004, the NICE guidance, based on level-A evidence, the highest level, acknowledged palliative care as a mainstream standard for the NHS. But since then, palliative care has not become mainstreamed and specialist palliative care services do not know from one year to the next whether there will be a contract for their services or whether they will, in effect, be closed down.
	I fully accept that sometimes resources need to be shifted, but I do not accept a shift that abandons the most vulnerable and distressed. A recent review of funding revealed that around 60 per cent of hospices were experiencing a real-terms decrease in funding contribution from the NHS. Only 20 per cent appeared to be maintaining or increasing the value of their NHS contribution and there appears to have been significant erosion of the value of the extra £50 million that the Government committed to services in England, with one unit experiencing a cut of £400,000.
	Some patients do have complex needs—for example, those with motor neurone disease. The Motor Neurone Disease Association, which supports the aim of my Bill, feels that all patients with MND need specialist palliative care because of the complex nature of the disease. The British Heart Foundation welcomes the Bill, as does Marie Curie Cancer Care, which points out that most palliative care is provided by the usual professional carers of the patient and family. Indeed, most generalist services could look after most dying people well if the basic rudiments of such care were a national priority for commissioners, and if the generalist services can access specialist advice whenever they need it.
	My Bill aims to ensure that such an infrastructure is in place and it gives the Secretary of State or the Minister in Wales the power to make regulations should they need to—but I hope that they will not find this necessary because good palliative care saves not only distress but money as well.
	Professor Mike Richards has done much to improve cancer services and he now leads the important end-of-life care strategy for the Department of Health. When this strategy has been fully developed I hope that it will not gather dust, as its predecessors have done; that would be a tragedy. My Bill is designed to ensure that commissioners and providers have to pay heed to a strategy and look at the way that dying patients are cared for in every service; they also need to recognise that specialist palliative care services can be small but that they point the way in raising standards. They are a cost-effective resource.
	The cost-effectiveness of palliative care cannot be measured just in relation to the patient. There are opportunity-cost savings from futile interventions—such costs are avoided by freeing up hospital beds by early discharge, by avoiding unnecessary hospital admissions through good anticipatory care and by decreasing morbidity in the bereaved by good care around the death. There is a shift from hi-tech to person-focused care. Based on current costs paid by the NHS, palliative care is the most cost-effective health service in the UK. But no care is cheap: the cheap option is no care.
	We know that many patients wish to die at home and that in some parts of the country that wish is being realised through high quality services. However, the number of hospital deaths has risen overall since 2002, and in 2004 the figure stood at 58 per cent of all deaths. Deaths in care homes seem to have fallen to about one in six in 2004 despite the same number of beds being in place in care homes. This trend has to be reversed. Strategy across all sectors of care needs to have some teeth. Currently, ignorance by staff and an inappropriate sense of defensive practice result in distressed patients being put in an ambulance and sent to emergency departments because their care has not been planned or properly co-ordinated.
	We have a devolved healthcare service, where decisions are being taken at a local level. Directives from the centre are not the NHS of today. But that is precisely why a strategy at a local level must be in place and, given 20 years of non-implementation of the executive letters, my Bill is needed.
	Moved, That the Bill be now read a second time.—(Baroness Finlay of Llandaff.)

Lord MacKenzie of Culkein: My Lords, I warmly congratulate the noble Baroness, Lady Finlay of Llandaff, on introducing this very important Bill to the House.
	I declare an interest first as a nurse, and secondly as a member of the All-Party Parliamentary Group on Motor Neurone Disease. In the days when I practised as a nurse, my specialty was operating theatres and trauma intensive care. I was fortunate during my general nurse training to work with, and learn from, a very talented charge nurse and an equally excellent staff nurse, who taught young students a great deal that was outside the then syllabus of training and which included much about social and spiritual needs in care as well as the basic essentials of nursing care for the terminally ill.
	One never forgets a good teacher or what they teach. In recent times, what has become known as palliative care has been reinforced for me by the very different treatment of two people I have known who lived with and then died from motor neurone disease. One had excellent support and care. For the other, the experience was a lesson in how awful and damaging poor communications within and between services and poor support can be both to the patient and to the family. I made reference to these cases in the recent Question for Short Debate on 31 January at col. 312.
	For those reasons I am delighted to support the Bill. I hope that we are pushing at open doors when asking the Government to give it a favourable wind in its progress through this House and another place.
	It has been the policy of both Conservative and Labour Governments for something like 20 years that palliative care should become a mainstream service. Although it is only right to acknowledge that some progress has been made, we are still a very long way from that happy situation. We are a long way from systematic planning and funding with the result that access to palliative care is more miss than hit. I think that it is correct to say that the majority of people who would benefit from such care are not getting it.
	At present, almost 80 per cent of adult in-patient palliative care beds are provided by charitable hospices. I welcome the promise in my party's most recent election manifesto to,
	"double the investment going into palliative care".
	Obviously, less than half way through a Parliament, we have not yet met that commitment, but what now concerns me is that the gap between what is spent by hospices on NHS services and the contribution from the NHS is clearly widening. In a recent survey, the National Council for Palliative Care reported that 35 per cent of respondents have lost resources in the past year. The gap in funding for NHS services through hospices is now coming from local fundraising—charity shops, donations and legacies. So I believe it is not only timely but right that, in a rich developed country, we focus much more on end-of-life care. It is not something that a comprehensive National Health Service can or should stand aside from.
	I take MND as an example. We know that it is a ghastly and usually rapidly progressing fatal illness which can affect any of us at any time. Most people with the disease become completely paralysed and cannot talk or feed themselves, although the intellect is almost always completely unaffected. Three people die from motor neurone disease every day, but on average only one of them will have been referred to specialist palliative care. Such a state of affairs, as well as geographical gaps in the availability of specialist provision and in the quality of that provision, cannot be acceptable in the 21st century.
	As the noble Baroness, Lady Finlay, said, an end-of-life strategy is to be published later this year. I do not know what the strategy will suggest but it will be surprising if it does not support choice for patients, regardless of diagnosis, about where they live and die, and provide the necessary care packages to make that possible. But to be blunt, I hope that the prospect of that strategy will not be used as a reason for not giving the Bill a fair wind. If enacted, the Bill will complement whatever comes out of the new strategy and ensure that the concept of palliative care goes beyond the definition set out by NICE in 2004. While that definition is appropriate to all care, palliative care relates specifically to patients with malignancies. Unless there is a duty to provide palliative care for all who need it, we will continue to have patchy provision or no provision at all. When there are stresses on funding, as in the present climate, the focus will not be on end-of-life care unless an absolute requirement or duty is placed on health care commissioners to provide palliative care.
	I welcome every one of the regulations set out in the Bill although I would like to see more emphasis in Clause 5(2)(f) on improving g co-operation within the NHS and social services as well as between those organisations and the voluntary sector. It was, among other things, the complete failure of communication within local health services and between them and social services that led to the most appalling catalogue of failure that I referred to earlier.
	There also needs to be a requirement to ensure the availability of specialist support which goes beyond providing care, treatment and psychological and spiritual support where there are complex care requirements such as in motor neurone disease. Unless specialist support is available, gaps in care will continue. It is important to ensure that palliative care professionals form part of any multidisciplinary team caring for people with conditions such as motor neurone disease.
	I again most warmly congratulate the noble Baroness, Lady Finlay, and am delighted to support this important Bill. I look forward to following its progress in this House and another place.

Lord Patten: My Lords, I share the strong feelings of support expressed by the noble Lord, Lord MacKenzie of Culkein, for the excellent Bill of the noble Baroness, Lady Finlay. I wish it a fair wind in this House. I have no interests of any sort to declare. I have never known anyone who has experienced hospice or palliative care, and I have no medical expertise of any sort, no medical legal expertise and certainly no medical ethical expertise to offer your Lordships' House, so I suppose that I speak as the average Peer in the street in support of the noble Baroness's Bill.
	The first thing that occurs to me is that there are gross inequalities in the provision of palliative care in England and Wales. One has only to look at the geography. It is reflected in the geography because the distribution of such services often seems randomly related to need. Secondly, there is also a considerable element of randomness in access to such services, for those with terminal illnesses, other than cancer, are grossly disadvantaged in their search for help—so much so that I think, to most people in England and Wales, the mention of "hospice" or "palliative care" equals "cancer care" for those who are dying of cancer. The fact is that only about one in 10 of those who get palliative care in a hospice or hospital is not suffering from cancer. So there is a geographical disequilibrium and there is also, I believe, a gross disequilibrium between different classes of patient suffering from different terminal diseases. The noble Baroness's Bill gives a clear road map for how this and other inequalities can be put right, and I congratulate her on that. It is very straightforward and easy to understand.
	I expect that the Minister will say in his wind-up speech—I must not try to pre-empt that of course—that to pick on palliative care is to pick out one bit of the National Health Service and that that is very unfair because there are lots of other important bits of the NHS, and it is wrong to pick out one bit of partly publicly funded provision for special treatment, which is, in itself, inequitable. That argument simply does not run and I hope that he will not use it, for, in fact, more than half the funding for palliative and hospice care comes from voluntary and charitable endeavour and not from state provision. I believe that, in that sense, palliative care is unique within the National Health Service; it is different, and it is certainly different in the very high level of satisfaction that all patient satisfaction surveys have shown, with the great majority being very satisfied with the care that they get. So we are dealing with something very unusual within the National Health Service, and it is important that we stress that.
	These duties need to be laid on Minister and commissioner alike to ensure greater equality of access and greater geographical fairness and also to make it clear that a disproportionate amount of what I think should be provided by the National Health Service is not dumped on charities and the voluntary sector in perpetuity. Perhaps I may give one example of how this is being played out now in London, not far from your Lordships' House. I refer to the Pembridge unit, which was set up not by a charity but by the NHS more than 15 years ago within St Mary's Hospital, Paddington. This unit has been threatened with closure. It used to have 17 beds; it now has 13—this in a densely populated area known for its problems of social exclusion with, I am told by one authoritative source, no less than 215 different languages and different dialects spoken by those who use the services of that hospital. That figure may not be right, but halve it and it is still a formidable number of different languages and dialects.
	This year, the Pembridge unit has to raise £400,000 sterling or shut. It has to raise £400,000 sterling next year or shut. That could be the end of palliative care in St Mary's unless help is forthcoming. So I hope that the Minister and your Lordships do not feel that I am making wild generalisations from the Back Benches about the problems that NHS-founded units have within hospitals.
	This sort of thing flies in the face of what I always thought was a politically bipartisan policy agreed by successive Governments over the past 20 years, as the noble Lord, Lord MacKenzie of Culkein, has just said in his excellent speech. Yet I think that now palliative care is too often marginalised; too often it has been sub-let to the voluntary sector and charitable bodies.
	After some recent debates in this place during the Committee stage of the Mental Health Bill, which are ongoing and in which, with his characteristic courtesy and care, the Minister also took part, the General Medical Council wrote to me out of the blue, which was kind of it, and sent me a booklet called Good Medical Practice. It may startle your Lordships to know that I read it. Out of the page at paragraph 3(d) leapt the following instruction to doctors by the GMC. It said that all doctors must,
	"take steps to alleviate pain and distress whether or not a cure may be possible".
	I simply do not think that doctors in the NHS can do that because of the lack of proper provision for palliative care.
	That point also highlights the need for good quality of life right to the end and for vigilance at both ends of the National Health Service spectrum of care. What do I mean by that? This is probably more a matter for other Bills and other discussions in your Lordships' House, but I mean that there is a paradox in that, at one end of the NHS spectrum, units, hospices and community carers are devotedly trying to help those in need who are facing a terminal illness and death. That is sometimes going on in the very same NHS hospitals or other facilities where, at least some would assert, there is increasing evidence that other people are not getting that help and that, indeed, their ends are being hastened by a covert nil-by-mouth strategy adopted by some clinicians and others to withdraw food and water. I do not know whether those allegations and assertions are true; I know only that it has been gone into in very great detail by a number of authoritative persons. One of our noble colleagues in your Lordships' House tells me that a dossier has been compiled with about 200 examples of such assertions and allegations concerning people who should be getting palliative care, not, in the end, death-inducing neglect.
	This is a very important issue and it will not go away. I ask noble Lords to imagine the public outrage if, as a matter of public policy, we decided to put down unwanted dogs and cats by shutting them away in a room and taking all the water and food away from them. That would not be seen as acceptable. This is business for another day but it is a marker that I wish to put down for the Minister, because it is business that will be pursued in your Lordships' House.
	Lastly, this Bill, when enacted, as I hope it will be, should help, not, as the noble Lord, Lord MacKenzie of Culkein, said, hinder the Government in ensuring that their new end-of-life care strategy is a success. I end my brief words with a request to the Minister. I know that he will be very busy in replying to the debate and that he will not be able to respond to many questions, but I should be extremely grateful if he could answer one question that I pose him in conclusion.
	I understand that, according to government announcements, the strategy is to be published in autumn 2007. Most of us know that timescales such as spring, summer, autumn and winter are very flexible in government parlance. Indeed, I fear that a form of administrative or governmental global warming might move the autumn season of 2007 inexorably deep into 2008. I should like to press the Minister to give a clear undertaking today that, by the end of the calendar year 2007—I am prepared to let autumn stretch that far—this strategy will be published.

Lord Lester of Herne Hill: My Lords, as the noble Baroness has clearly explained, the Bill has the important aim of securing the provision of good palliative care to everyone with a terminal illness. The debate is timely, coming in the wake of the debate introduced by the noble Baroness, Lady Jay of Paddington, on 31 January on this subject.
	This year is the 40th anniversary of the opening of St Christopher's Hospice. Led by its founder, Dame Cecily Saunders, it marked the start of a highly influential movement to improve end-of-life care world-wide.
	Everyone in this House will surely support the aim underlying the Bill. As the Minister will explain, the Government clearly do so. They have increased funding for hospices significantly and support the NHS End of Life Care programme. That programme's aim is to improve the quality of care for those patients and enable more patients to live and die in the place of their choice.
	The principles of good palliative care were well stated by Help the Hospices, taking as its starting point the affirmation of death as a natural part of life. Built on that bedrock are the values of respect, choice, empowerment, holistic care and compassion. If there is to be a statute, its definition of good palliative care should encompass the philosophy of Help the Hospices and address some of the difficulties in the provision of medical treatment to relieve pain and suffering. It would also need to give effect to the Government's commitment to increase choice for all patients regardless of their condition within available resources, and to meet the treatment needs of the patient.
	It is important to give effect in such a Bill to the rights of patients to personal autonomy and self-determination in their medical care and treatment. That right is enshrined in the principles on which the Mental Capacity Act 2005 is based. The draft code of practice, which was laid before Parliament yesterday, anchors that clearly. Palliative care is broadly defined in Clause 7 of the Bill as,
	"care given with the intention of improving the quality of life of persons with a terminal illness by ... treatment which controls and relieves pain, distress, discomfort or other symptoms caused by, related to or coincidental with terminal illness, and ... psychological, social and spiritual help and support".
	No reference is made in that definition to the wishes or choices of the patient. Palliative care must surely be grounded in the wishes and the consent of the patient. That goes to the heart of what good palliative care should be about. It is the patient rather than the medical team who experiences the pain, distress, discomfort or other suffering; and patients with mental capacity know whether the care they are receiving meets their needs. The statute would need to recognise patient autonomy to make clear that the provision of good palliative care must not be based on the outdated paternalistic model of the doctor deciding what is in the patient's best interests.
	The other issue that I wish to raise is the vexed question of medical care and treatment for patients, where the relief of pain or suffering may have the likely or inevitable consequence of foreshortening life. The doctrine of double effect permits doctors to administer potentially lethal drugs, provided their intention is not to kill, but simply to relieve pain and suffering. Professor Seale published two reports in 2006 to assess the frequency of different end-of-life decisions in the United Kingdom and the degree to which patients' lives are shortened by end-of-life decisions. Based on a study of 857 doctors, he found that in one-third of deaths, patients were medicated to alleviate symptoms with a possibly life-shortening effect.
	The Law Commission's 2006 consultation paper on a new homicide Act for England and Wales states:
	"It is now an accepted part of common law that a doctor may lawfully prescribe such medication"—
	pain relief that may shorten life as a consequence—
	"in such circumstances and, thereby, have a defence to a charge of murder".
	But the principle of double effect does not sit well with the current formulation of intention and the law of homicide, and the absence of a proper legal framework and the risk of prosecution undoubtedly deters some doctors from treating their patients in accordance with those patients' wishes The December 2005 trial of Dr Howard Martin, who was found not guilty of murdering his patients by administering high doses of morphine and diamorphine, demonstrated the practical problems in applying the principle of double effect.
	Reasonable legal certainty is especially important where a patient is suffering from a terminal illness and facing the prospect of experiencing severe suffering and indignity. Patients have the right to life. They also have the right to personal autonomy and to live and die with dignity. They, their doctors and other healthcare professionals need to know what exception there is to the law of homicide enabling a doctor, acting in accordance with the patient's wishes, and the doctor's judgment as to the appropriate medical treatment, to administer that treatment, even though it is virtually certain that it will hasten the patient's death. Unless the criminal law and good medical practice are clear, conscientious doctors, seeking to act in the best interests of their patients, are left in a state of uncertainty—as are their patients.
	Some things are clear. There is no doubt that the intentional taking of life, albeit at the patient's request or for a merciful motive, is unlawful. For a doctor to intervene actively to bring about a death is unlawful. Equally, a doctor who owes a duty of care to a patient and who withdraws or withholds treatment without lawful excuse commits an unlawful act. It is also clear that a competent adult has the right to consent to, or to decline medical treatment, even if the decision would result in the patient's death.
	The problem with the existing state of the law is for the doctor or other healthcare professional to know what can lawfully be done to relieve pain or suffering towards the end of a patient's life without fear of prosecution. One problem concerns the relationship between intention and foresight in deciding whether a doctor has a criminal intent. In deciding whether there is the mental element necessary for murder, foresight of the consequences is usually evidence of the existence of a criminal intent. The greater the probability of death as a consequence, the more likely that it was foreseen, and the greater the probability that it was also intended.
	As the noble Baroness, Lady Andrews, pointed out during the Second Reading debate on the Patients' Protection Bill,
	"In criminal law, when juries are asked to consider 'intent' factors they may be asked to take into account the probability of the outcome and the extent to which that was appreciated by the defendant even if it were not their main intention. Therefore, if a doctor knew, as a virtual certainty, that withholding or withdrawing treatment"—
	or, I would add, giving treatment—
	"even at the patient's request, would result in"
	or, I would add, would hasten,
	"the patent's death, the doctor could still be held to have positively intended the patient's death".—[Official Report, 12/3/03; col. 1433.]
	When a doctor acts in accordance with what she or he considers to be responsible medical practice, with the aim of relieving pain or severe distress but with the probable consequence of hastening the patient's death, the risk to the doctor is that the jury, as directed by the judge on currently declared legal principles, will impute the necessary specific intent to find the doctor guilty of culpable homicide, and the judge will have to impose a mandatory sentence of life imprisonment.
	The humane theological doctrine of double effect attempts to provide a justification for administering drugs necessary for the relief of a patient's pain or severe distress in the knowledge that a probable consequence is the shortening of the patient's life. But the absence of a clearly prescribed legal framework and the risk of prosecution undoubtedly deter some doctors from treating their patients in accordance with the patient's wishes and the doctor's conscientious beliefs.
	This uncertainty and confusion could be addressed if the definition of palliative care were widened to cover the giving of treatment, irrespective of whether it is likely to shorten life, while making clear, as does the Mental Capacity Act, that it is unlawful to give treatment with the motive of shortening life.

The Lord Bishop of St Albans: My Lords, I join everyone here in welcoming this profoundly important Bill and in congratulating the noble Baroness, Lady Finlay of Llandaff, on her far-sighted determination to create a Bill that has the potential to bring real care and comfort to the people of our country.
	When I was a parish priest I had the privilege of being involved in the work of a local hospice. To be with patients, families and staff as individuals made their journey towards death was humbling and deeply moving. Years later, I can bring particular individuals to mind. I think, for example, of a very senior military figure dying in that hospice. Suddenly and unexpectedly, all his terrible experiences of the Second World War erupted. He was very perturbed. In that hospice, the provision of physical, emotional and spiritual care meant that he ultimately went to his death in peace. I think of an Austrian woman with no family whatever, who described the hospice as the best trade union she had ever belonged to, because she discovered a sense of human solidarity there—remember: no family, no relations, no one but herself.
	Now that I am a Bishop, I have the privilege of being patron of a number of hospices in Hertfordshire and Bedfordshire. I witness palliative care of a high order in each, based upon a number of implicit and explicit beliefs. First, each human being has absolute worth and value, and must therefore be treated with compassion, respect and love. Secondly, dying can, paradoxically, be part of a healing process for the person who is dying and for their family. Thirdly, the attention given by society to the dying is usually a measure of how it treats the living. Fourthly, each individual's spiritual and religious needs should be accorded as much attention and care as their physical and emotional needs. I shall briefly concentrate on that last point.
	It seems to me that every one of us, whether we practise a religious faith or not, has an indefinable but irreducible core for which the word "soul" is the most appropriate description. If we do not treat people's inner beings, their souls, seriously, we are failing to treat them with that respect and compassion which is the inalienable right of all human beings. For those of us with a religious faith, of course, our spirituality is shaped by and given expression through that faith, but when I use the word "soul" I refer to every human being whether they have a faith or not. Religion and spirituality are not necessarily the same.
	If what I have said is true, it follows that we cannot talk of palliative care being adequate or good if it does not take seriously the spiritual and religious needs of each one of us. I join with others in welcoming the Government's creation of an end-of-life strategy group; though that seems the kind of title George Orwell would have given anything to create. In its initial remit and the make-up of the board, however—with the greatest respect to all its members—there seem to be some gaping holes. In defining its task, the strategy group uses almost exclusively mechanistic language. There is much talk of "leavers". In Professor Richards's letter to his colleagues, just over a single side of A4, the word "leaver" occurs no fewer than four times. It is of course accompanied by talk of "underpinning" and "delivery". I understand such language, but can someone please tell me why the word "spirituality" is not mentioned in a strategy devoted to improving palliative care? Language is always significant, and if we use only mechanistic language to shape our thinking about palliative care, we shall end up treating human beings like robots.
	I hope I have not got this wrong, but I have been told that there is not a single member of the hospice movement in this end-of-life strategy group. The group, quite rightly, includes someone to ensure that racial equality issues are not overlooked. Can someone please explain why there is no one from the hospices? Why has that movement, which has thousands upon thousands of dedicated volunteers and totally devoted, experienced and professional palliative care personnel, been overlooked? I suppose I would say this, but if it is true, as I have said, that every single human being has a soul, why is there no representative from the fields of spirituality or religion? In common with other priests in this country, I have sat with dying people time after time. I have heard the confessions of the dying. I have taken hundreds of funerals. Does that have nothing to contribute to a group looking at end-of-life strategy?
	The Bill is so important because it will deeply affect our entire nation. It is based implicitly upon the value and worth of every single human being, and implicitly desires for each one of us the best and most peaceful death. But it will be in the implementation of such a Bill that the real test of this proposed legislation will be found. We shall need to keep a careful eye on that implementation process, to see whether the dominant metaphor is of human beings as machines, or as living souls. I, no doubt along with everyone else here, warmly welcome the Bill. We have before us the opportunity to ensure the best palliative care pathway for everyone in our country, but its potential will be truly fulfilled only if the values implicit within it are made explicit in its application.

Lord Carlile of Berriew: My Lords, I am sure that the whole House would wish to join me in expressing our deepest sympathy to the noble Baroness at her sad and recent loss. I am sure also that the House would agree that she spoke with great fortitude in the circumstances. That she was able to make so cogent a speech in those circumstances is no surprise to those of us who have heard her speak on many occasions; nevertheless, it was a remarkable occasion.
	I join in congratulating the noble Baroness, Lady Finlay, on introducing this Bill, which I support very strongly. When thinking about the Bill I was struck by the contrast we make in the way we speak respectively about birth and death. I am obviously a child; I am also a parent and a grandparent. I have known the sadness of death in the family and the joys of many births, including those of five grandchildren, and I hope more to come. We talk about birth always in terms of joy—a good birth, a happy birth; we talk about the contrast between the pain of childbirth and the joy of the child arriving. In my view there are equal points of good practice, of even joy, to be made about death, but somehow we do not speak about these things as often as we should. The noble Baroness's Bill helps us to address these issues head on.
	When my father died at a great age, we enjoyed—I use that term deliberately—as good a death-bed scene as one could imagine. He was dying of a painful cancer, but through the intervention of palliative care specialists, in which I include his general practitioner, we were able to face that death with a degree of pleasure. Indeed, I recall the last words he said to me. He was always of the view that I was very scruffy, and he and I being exactly the same size, his last words to me were, "Wear my black suit at the funeral". I wore his black suit when I read the reading at his funeral. One should be able to remember death in terms of joy like that whenever possible.
	I want to make a point in a few moments about the doctor/patient relationship, which is important in dealing with the purpose and the structure behind the noble Baroness's Bill. The doctor/patient relationship is very different from the days when my father was a general practitioner in Burnley, Lancashire, where we lived in the surgery in which I was brought up. Of course I recognise that medicine is much more technological than it was in those days, and it is neither possible nor desirable to have the same doctor/patient relationship as there was then, because so much more can be done for patients than simply enabling them to talk to a sympathetic general practitioner. Nevertheless, there are issues about that relationship that are relevant to this Bill, to which I will turn in a few moments.
	Specialists such as the noble Baroness, Lady Finlay, who is most distinguished in this field, have done a great deal to bring the United Kingdom to the forefront of the possibilities, if not always the practice, of best palliative care. I applaud the Government's manifesto commitment to double the investment in palliative care. Help the Hospices says in its briefing for this debate, however, that,
	"the gap between what hospices spend on NHS services and what the NHS contributes is estimated at £150-£200 million and is widening. Most hospices are suffering a real terms cut in their funding, leaving many hospices reliant on local fundraising"
	to provide what we should regard as essential services.
	There are pressures from elsewhere. My noble friend Lord Roberts of Llandudno—a Methodist minister with some expertise, he tells me, in matters relating to gambling—has drawn to my attention this morning a real issue arising from the Gambling Act. Many hospices that run lotteries and take contributions by telephone and on the internet now have to stump up substantial licensing fees, which bring the very viability of those lotteries into question. Sometimes we know not quite what we do when we introduce yet more regulation. I invite the Government to look at that issue facing hospices and similar organisations to see whether four-figure licensing fees are really necessary.
	I am concerned about inconsistent commissioning practices. Primary care trusts can decide with little or no warning to reduce commissioning levels or funding. That results in unexpected and unpredictable pressure on charitable income and causes considerable difficulties for the trustees of hospices.
	I shall now make my doctor/patient relationship point. A few years ago the Welsh Assembly Government granted me the privilege of writing a report on the safety of children in the National Health Service in Wales, Too Serious a Thing, in which I was assisted by many medical experts. The preparation of that report gave me the opportunity to look at the NHS in every aspect as it affected children—the optician, the school nurse, the general practice, the accident and emergency unit, the hospice, child and adolescent mental health services, and every other part of the NHS operating in Wales. The basic observation I made as I sat down to write that report was that there were patients and there were providers of services—the NHS, for the most part—but there was not much relationship between the two.
	I am one of those old-fashioned Liberal Democrats who believes in the principle of duty: that the state has duties and that equally citizens have duties. We cannot expect the state to work on our behalf if we do not do our bit as partners in the state in which we live. That seems to me the essence of a liberal democracy.
	As it happens I went to my general practitioner this morning with a minor ailment. I was able to be seen very quickly; I was prescribed; I went to a chemist; I collected the drugs; and, as it happens, I applied them in the gentlemen's lavatory on the first floor West Front when I arrived here to speak in the noble Baroness's debate—that is perhaps more detail than your Lordships need. It stuck me as I was going through this process, which is very real to me today, that although my general practitioner could not have been more helpful, I was not really a stakeholder in any contractual sense in my relationship over that minor ailment with the National Health Service.
	I return to something I mentioned earlier; it is what I called the principle of duty—that is not my phrase, it is used very skilfully in a seminal work by David Selbourne. If I have a compact with the National Health Service and the National Health Service has a compact with me, if there is a quasi-contractual relationship between the citizen and the state, it all becomes much more meaningful.
	In my view, the framework of the Bill could well be replicated elsewhere. It makes the patient and the state stakeholders; it makes them contracting parties. It means that there are rights—this will trouble the Government—that can be enforced. Surely, when we pay our taxes for the huge National Health Service, we should be able to enforce those rights in roughly the same way as when we go for private medical treatment. The Bill contains a useful framework that could be replicated in many parts of the health and other public services. It is right that such relationships should exist and should be fostered by legislation.

Baroness Greengross: My Lords, when I had four very young children, I had a close friend and neighbour who was about the same age as me, in her late 20s or early 30s, who had a second child and then contracted the sort of fast-advancing cancer that can attack young women soon after they have babies. I was deeply shocked. I was very fond of her and we were close friends. She spent the last few weeks of her life in a hospice and we spoke on the phone most days. She told me repeatedly that her last weeks—the time in the hospice—were a very beautiful experience for her and for her young doctor husband. I never forgot that, as I shall not forget the speech that the noble Baroness, Lady Gardner, just made. You do not forget things like that and we are deeply moved. I thank her very much for talking to us in that way.
	Perhaps I may say how much I support the Bill and its aims. I have a total commitment to and belief in the value of good palliative care, as exemplified by the work of my noble friend Lady Finlay, whom I hold in the highest regard. As a result of many years of work with older people, I became extremely concerned at the lack of good care that so many people experience at the end of their lives—those who are denied palliative care at its best. I pay tribute to the many people, professionals and others, who provide such care to dying people, sometimes in very difficult circumstances and I congratulate the Government on increasing the level of funding available for palliative care. Having said that, I am sure that we all agree that there remains much work to be done and a great need for additional resources if we are to get the provision right.
	We must ensure that there is greater availability of palliative care to a much broader range of people, often with complex conditions that require specialist attention. It has been heartening to see palliative care start to engage with the challenges of neurological conditions, in particular. I make a special plea for the Government to help to improve the care given to people suffering from dementia. By the time that someone suffering from dementia is admitted to continuing care, they are likely to be within the last two years of their life. Their needs are physical, emotional, psychological and spiritual. Like all Members of the House, I was moved by the speech made by the right reverend Prelate, on which I congratulate him. Much of what has been said today is unforgettable. Much more needs to be done to ensure that the care given to people with dementia meets all those needs. I know that my noble friend Lady Murphy, who is unfortunately unable to attend today's Second Reading, feels strongly about that and shares my view of the priority that must be given to people suffering from dementia.
	I turn my attention to patient choice. My noble friend Lady Finlay emphasised that that is an important concern, especially as the person reaches the very last stages of life. There is now a more general acceptance of the holistic approach that is needed to the subject of dying, which recognises the process of dying as a life stage for which, like any other, we need to prepare if we can and over which we should be able to exercise as much choice and autonomy as possible. The Government have recognised the importance of choice, dignity and other factors both in their Dignity in Care campaign and in their emerging end-of-life care strategy.
	The key to helping every individual to achieve the kind of death they long for is to recognise him or her as an individual with individual requirements and needs. Two people may be dying from the same condition but may well experience it in different ways, both physically and mentally. Consequently, they will make different choices about how they want to live their final months, weeks, days or hours. One person may want to die at home; another would find it reassuring to be in hospital. One may want to try every last treatment option available; the other may tire of medical interventions. One person may suffer greatly because she is unusually sensitive to the medication that her symptoms require; the other may experience less pain but find it distressing to receive care from a young person of the opposite sex. Two people may wish to spend the time they have remaining in very different ways and consequently want very different things from palliative care.
	If we do not achieve as much choice as possible in the process, we will fail the dying. Palliative care should therefore be rooted in the wishes of the patient. For that reason it is important that the principle of patient choice is built into my noble friend's Bill to ensure that the Bill and palliative care take the individual patient's needs and wishes as their starting point and protect the discipline against any charge of paternalism.
	We all recognise that palliative care is not provided exclusively in a hospice setting. Figures from the ONS tell us that most people do not die there, but in hospitals or at home, including in care homes. The majority of our population wish to die at home, the next preference being in a hospice. Much more needs to be done to extend excellent palliative care into all settings and across the NHS, as stated in the Bill. Even in the most up-to-date and best equipped hospital, staff may not be able to devote the time, space and attention that a dying person deserves. I should like the best features of hospice provision included somewhere in all hospital premises, so that the terminally ill patient can have the best of both worlds: an appropriate setting with privacy, time for family and friends to be together in comfort; and first-rate medical support close at hand. Although only a small number of people die from a recognised terminal illness in care homes, they may face inadequate treatment due to the lack of appropriately trained staff or they may be transferred to a hospital for the final stage of their lives, perhaps against their wishes. Neither is acceptable.
	Ultimately, palliative care is about good care and the relief of suffering, but we know that there are circumstances in which some dying patients still experience considerable suffering, which even excellent palliative care does not relieve. I know that that is true of only a small minority.
	The noble Lord, Lord Lester, spoke eloquently about the need to respect the autonomy and choice of people at the end of life and the need for clarification of the law to ensure that people have, and know that they will have, adequate care and pain relief wherever they are. Doctors need to know that they are not at risk of being prosecuted for employing what we believe to be good practice. The noble Lord, Lord McColl, whom I admire enormously for his work, noted in last month's debate that there is a problem here because doctors are wary of giving analgesics, especially when there is respiratory distress. We want to clarify what doctors can and cannot do. Perhaps that could usefully be explored in Committee.
	Palliative care is the last opportunity we have to treat and care for a person at a stage when their dignity must be maintained and cherished to the end. This Bill will go a long way to ensure that that happens. It deserves our wholehearted support and that of Her Majesty's Government.

Lord Colwyn: My Lords, I thank the noble Baroness, Lady Finlay, for introducing this Bill. Patients who are dying should have access to the same attention and standard of healthcare as all other patients. This access should be provided equitably to all groups in society. That was made clear in the powerful and emotional speech of my noble friend Lady Gardner, which, I, too, will remember. Most speakers so far have supported the Bill. I support the aims of the Bill but suspect that the Government will be reluctant to accept legislation on the provision of specific services. The General Medical Council supports the aim of ensuring that adult patients nearing the end of their lives should have access to high quality palliative care, both in hospital and in community settings, regardless of their diagnosis.
	Thirteen years ago, I was a member of the House of Lords Select Committee on Medical Ethics, which was appointed to consider the ethical, legal and clinical implications of a person's right to withhold consent to life-prolonging treatment and the position of persons who were no longer able to give or withhold consent. One of the many conclusions that we reached was that resources for healthcare are not and can never be infinite. Healthcare teams should not be required to make decisions relating to resources in the course of day-to-day clinical care of individual patients. Their concerns should be for that individual's welfare. Decisions about treatments which society can or cannot afford should be made elsewhere than in the hospital ward or doctor's consulting room on the basis that such treatments as society wishes to fund must be made available equally to all who can benefit from them.
	We recommended that high quality palliative care should be made more widely available and that research into new and improved methods of pain relief and symptom control should be supported. The training of healthcare professionals should do more to prepare them for the difficult ethical responsibilities which they carry by giving more priority to ethics, counselling and communication skills.
	Many members of the committee believed that a solution to euthanasia was a development and widening of the hospice service. We visited different hospices and were tremendously impressed with the facilities for and the treatment of patients. Although in 1994 there were nearly 200 centres working with many more community and home-care teams, it was suggested that hospice care was not available to the vast majority of dying patients.
	The committee thought that there should be further research into pain relief and symptom control so that the standard of palliative medicine that many of us had seen should be available in hospitals and the community throughout the country. The Conservative Government's response to this part of the report was described as timid and, although stating a determination to see good quality care, the Minister declined to recommend any increased funding for palliative services.
	In his reply to the recent debate on 31 January, the noble Lord, Lord Hunt, accepted the points made about the need to expand palliative care and indicated that the new end-of-life care strategy under the leadership of Professor Mike Richards would set a framework and would ensure that good quality palliative care is more widely available. I look forward to his comments on the membership of that group, as pointed out by the right reverend Prelate.
	As advances in medical science lead to new technology and drugs, decisions about life and death become more complex. The ability to prolong life can now subject the terminally ill to a dependence on technology which is stressful for patients, their families and healthcare professionals. Misconceptions among medical staff can lead to under treatment and a hesitancy about providing the necessary degree of pain relief for fear of drug tolerance or shortening the patient's life.
	I am grateful for the briefings that I have received from various organisations—the National Council for Palliative Care, Help the Hospices and the General Medical Council, to name but three. They all support the noble Baroness's initiative, believing that the Bill will strengthen and extend the provision of palliative care. The GMC welcomes the Bill as it coincides with its published guidance, Good Medical Practice, and its planned review of standards expected of medical graduates in order to gain entry to the medical profession. As the noble Baroness, Lady Finlay, has said, it has promised to ensure that the themes of this debate are included in the review.
	My noble friend Lord Patten suggested that most of the changes in developing palliative care have been in relation to cancer, but of course it applies to those with other conditions. Non-malignant diseases, including circulatory, respiratory, neurological and dementia are responsible for many more deaths. Palliative care should be developed for all those who need it, including all terminal illnesses. It is still not a mainstream service and inequities persist. I hope that this Bill, or perhaps the discussion we have on this Bill, will be part of the development process.

Baroness Masham of Ilton: My Lords, I thank my noble friend Lady Finlay of Llandaff for this humane and necessary Bill. Why do I think it is necessary? The services of palliative care throughout the country seem to be very patchy. I know that from personal experience. My husband died 11 months ago, having lived for many years with several different medical conditions, which were the result of strokes, diabetes and Parkinson's disease. He had a bleed in his head from too much Warfarin. A thrombosis developed in hospital: he was discharged with it and then had to be admitted to another hospital as an emergency. He got cellulitis. Later on he also developed a cancerous tumour that resulted in an open wound which had to be dressed twice a day. I am pleased to say that treatment with Warfarin has thankfully improved from the early days and is now monitored regularly, I hope, for everyone who needs it.
	Over the years, we had many dramas, some excellent medical treatment and some which could have been better. But in the last few months of my husband's life, I was extremely grateful for good advice from my noble friend about palliative care. As a professor of palliative care, the noble Baroness, Lady Finlay of Llandaff, is the ideal person to introduce such a Bill to your Lordships' House. Already this Bill has engendered a great amount of interest from the GMC to many voluntary bodies, which is excellent. Perhaps everyone speaking in this debate should declare an interest. One never knows when any of your Lordships or I may find ourselves at the receiving end of palliative care.
	The weekend my husband died I had to rely on the out-of-hours doctor services. As my husband's condition deteriorated and he was running a temperature, on that Sunday I had to wait three hours for the doctor to telephone back. When she did, she offered no help; only to say that she was unable to find a physiotherapist to help with his breathing. As she was 24 miles away, she did not bother to come out. Because of the risk of hospital infection, the GPs thought that it was better for my husband to be at home, but the community could not offer the assistance that he needed on that last Sunday. The next doctor to whom I spoke sent an ambulance and we took my husband to hospital, with all the drama that that involved. He died of pneumonia while still in the accident and emergency department, without doctors being able to access his notes because they were in the GP surgery and the other local hospital—and it was a Sunday. As it was classified as a "sudden death", the police were involved. This is why I find the Bill so important.
	I am told that there is a voluntary gold-standard scheme for GPs which includes a quality framework for palliative care, planning for the patient's end of life, in which the patient and his or her family are involved, and the out-of-hours doctor service being informed of people in a palliative care state in their area. Will my noble friend encourage this service throughout the country? I believe that such a scheme exists in Cambridge. Perhaps one day it will reach North Yorkshire.
	I am pleased that the Bill has already brought items of good practice to the notice of some of us. I am glad that the General Medical Council has stated that it supports the aim of ensuring that adult patients nearing the end of their lives should have access to high quality palliative care, both in hospital and community settings, regardless of their diagnosis. It also agrees that it is important that access to such services should be provided to all groups in society. I hope that these services will include out-of-hours doctors because so many things happen at week-ends and during the night.
	I am also pleased that the GMC welcomes the opportunity provided by the Bill for further consultation on how palliative care services should be provided. The debate is timely because it plans to review over the coming months the standards expected of medical graduates in order to gain entry to the medical profession. It can ensure that the themes of this debate are included in this review.
	I hope it will also include the specialist needs of patients with swallowing problems, such as those with Parkinson's disease and motor neurone disease, and patients who are vulnerable to pressure sores, such as those with spinal injuries. However basic the needs, they should be included in high standards of medical education.
	Cases such as the 86 year-old diabetic lady who died in Doncaster Royal Infirmary when she developed leg ulcers after a gall bladder operation last July should be avoided at all costs. It was discovered that ulcer wounds on her legs had become infested with maggots when she was being treated on a ward. Her hospital post-mortem examination reported that she had died of old age, but her family were so unhappy with the findings that they made a formal complaint of criminal negligence to the coroner. The police were called and, in a second examination by the Home Office pathologist, it was found that blood poisoning primarily contributed to her death. The lady's daughter is a nurse and she condemned the appalling standards of care. Vulnerable patients need particularly good care and there should be no cover-up when things go wrong.
	People in the last stages of their lives receiving palliative care may be immuno-compromised for many different reasons. Transplant patients and patients receiving drugs for cancer, HIV or liver disease, as well as people with long-term disabilities, are very much at risk—and many have died—from the dangerous infection Clostridium difficile, now rife in many hospitals and care homes. It causes debilitating liquid diarrhoea. This week I was shown by the company ConvaTec an interesting faecal management system—Flexi-Seal FMS—which collects liquid faecal matter from unfortunate patients should they contract C. difficile. If any of your Lordships are interested in seeing this device, I have one in my office. It is hopeful that companies are trying to help patients and staff in these difficult and unpleasant circumstances. The device will save changing a bed many times a day.
	I would like to ask the Minister this question: what guidelines or protocols are there for the NHS in the treatment of infection-related faecal incontinence—for example, C. difficile? I stress how important it is for patients receiving palliative care in their own homes to have their wound, stoma care, urology and incontinence products delivered. Thousands of patients depend on this service and the companies provide support to patients, carers and clinical nurse specialists in stoma care, urology and continence. I hope this service will continue. It is under consultation at the moment, having been extended until 2 April.
	The Bill seeks to facilitate the spread of best practice and to drive up standards. It would seem incredible if anyone disagreed with these aims. It is an appropriate time to discuss the Bill, just two days after Ash Wednesday. Good palliative care should also include spiritual support when it is wanted. Very often people who have lapsed want to come back to it at the last stage of life.
	Good care is not expensive but bad care can be very expensive as there can be all kinds of breakdowns in many directions. I wish the Bill a speedy, successful journey through your Lordships' House. It has been a privilege to take part and share in the debate today.

Baroness Howe of Idlicote: My Lords, it is a privilege to follow my noble friend Lady Masham of Ilton and to take part in this remarkable and moving debate on the Bill of my noble friend Lady Finlay of Llandaff. I pay tribute to the many memorable speeches we have heard today, in particular that of the noble Baroness, Lady Gardner of Parkes.
	My noble friend Lady Finlay of Llandaff has achieved a huge amount already in promoting palliative care. Her introduction of the Bill is an important—indeed, essential—step in ensuring that the topic is very firmly placed at the top of the nation's healthcare agenda. It is a most welcome reinforcement of the Government's recent thinking on the end-of-life care strategy.
	No one, of course, is surprised that this service, like so many other philanthropic good causes, began with voluntary charitable work. Palliative care and the hospice movement generally have remained largely dependent on the voluntary and charitable sectors for fund-raising and for mobilising the human resources, skills and training needed to tackle the task.
	One wonders why so much started by the voluntary and charitable sectors has become the responsibility of the state. I believe that there are two explanations. The first, which is undoubtedly true, is that the expertise developed by organisations such as Marie Curie and Macmillan Cancer Support have so qualified them that, with quite modest backing from the public purse, they are uniquely well qualified to deliver this increasingly community-valued end-of life-service.
	The second explanation is of a rather different kind, and follows in a way the comments made by the noble Lord, Lord Carlile: it is the impact of what I believe is a developing change in the balance of public perception. We have long celebrated, both in families and as a nation, the birth of every baby—his or her start of life. Medical investment in that has been enormous. So, too, have we applauded every improvement in infant mortality rates. But until recently, at least, the circumstances of that same baby's end of life has not been seen by successive Governments—nor, to be fair, by the rest of us—as having anything like the same importance. We fail to value or celebrate his or her contribution to family, the community or indeed the economy. Bluntly, those facing end of life have not been a priority for government spending.
	People carry the scars from bad care they have witnessed for the rest of their life. We have heard some appalling examples of that this morning. It is unsurprising that there has been a reluctance to think, let alone talk, about when—still less, how—one's death will happen. The most, perhaps, that we have all hoped for until recently has been for a quick, sudden death. Now, however, more and more people are seeing, many of us within our own circle of family and friends, that with palliative care expertise the end of life, though inevitably sad, can be positively reassuring for all involved.
	I mentioned one such family's experience when last I spoke on this issue. That same family today is still talking about the comfort and enrichment that that whole experience gave them. That is why this Bill is such an important pointer to a future that is better balanced between birth and death, for there are still far too many circumstances in which palliative care is just not available, and too many communities, towns and even districts where it is barely available at all. We should prefer to die in our own home; we have heard that reinforced. Marie Curie's 64 per cent is a striking percentage.
	The crucial requirement, I argue, as your Lordships have done before me, is for all those who are involved in the provision of end-of-life healthcare to have access to resources that will allow them to establish partnership or other arrangements that will secure the best provision of the best possible palliative care. The Bill addresses just that need. Unless the state provides the necessary funding, the palliative care postcode lottery will continue. That means, as usual, that the most deprived areas are the least likely to have the excellent arrangements that we, for example, enjoy in south Warwickshire. Quite apart from the availability of at least three local hospices, we have a well spread, widely supported voluntary organisation, Shipston Home Nursing. Two key features of that are that the chairman is a senior partner in the local GP medical centre, and that there remains open nearby a small local National Health Service hospital from which the combined half-voluntary, half-public seven-day service is organised.
	That is the kind of standard we should be seeking to achieve elsewhere—everywhere—not just because patients are getting a more appropriate, personal and choice-based service; Shipston Home Nursing is also making a substantial saving for the National Health Service. One patient being cared for at home last Christmas saved the cost of one month in a hospital bed—about £15,000.
	The follow-up document, published in October 2006, to the Government's White Paper illustrates some of the other encouraging pilots and partnerships already under way, which will spread knowledge of, and training for and in, palliative methods. It is especially encouraging to read of Marie Curie's Delivering Choice programmes in Lincolnshire, Tayside and Leeds. All those are steps in the right direction, arising from a growing conviction that the palliative care approach is the right one for all older people at the end of a long life. Arrangements of this kind are already demonstrating that, by providing a rapid-response range of services for those at home, a considerable saving in hospital admissions is achieved. There is a long way to go on that, however, and there are many circumstances in which people will call an ambulance because they are so concerned and unsettled by what they see in a loved one, as my noble friend Lady Masham pointed out.
	The saving as far as hospital beds are concerned is a claim that all palliative care enthusiasts have made for some time. The research by Professor David Taylor and Sarah Carter suggests that for every £1 extra invested in community palliative care, £2 is released to the acute hospital sector.
	Even against that background, the Government's commitment to provide £50 million towards refurbishment of hospices, although of course welcome, will not be remotely enough to ensure that adequate resources, facilities and training for palliative care staff are available throughout England and Wales. That is exactly why my noble friend's Bill is essential, if anything like the Government's own plans for palliative care are to be achieved. I join others in hoping that your Lordships will be hearing from the Minister today that the Government will indeed support the Bill.

Lord Cavendish of Furness: My Lords, it is with real pleasure that I support the Bill, introduced with such eloquence and authority by the noble Baroness, Lady Finlay of Llandaff. It would be hard to exaggerate the contribution that she has made in this field. She combines the hard-headed approach of a distinguished scientist with the humanity that comes of a penetrating understanding of human suffering. It is a combination that I welcome, especially as there appears to some of us to exist in recent months a trend for the end-of-life debate to pit the scientific approach against the humanitarian one, when I think that most reasonable people believe that it should draw on both.
	As on previous occasions, I need to declare my personal interest in the Bill. I was one of the founders of St Mary's Hospice in Ulverston, south-west Cumbria, in the late 1980s; I have been continuously involved with the organisation ever since and am currently chairman.
	I have regaled your Lordships on the problems we have faced at St Mary's through our gross underfunding and through the failure on the part of the then PCT to understand what the hospice was about or to deal fairly with us. Although there remains very little improvement on the very low 10 per cent funding we have historically received from the Government, I have grounds for mild optimism, and that optimism grows stronger with the introduction of the Bill.
	Echoing my noble friend Lord Bridgeman, I say that at 10 per cent funding in an area such as mine, it has been a very painful operation to keep going, and it is completely unsustainable. I cannot ask local people to contribute 90 per cent for this sort of operation.
	This measure seeks to enshrine in law what has in effect been the policy of successive Governments for the past 20 years or more. Apart from providing a statutory framework to ensure that palliative care becomes a mainstream service, it provides for its effective delivery for all who need it. In addition, and very significantly from the point of view of those who run a hospice, it requires commissioners to identify need in their area, demonstrate transparency in publishing their plans of action and account for the progress they are making towards improving core palliative care services.
	I do not know whether the noble Baroness had any choice over the timing of the Bill's introduction. For me, the timing is perfect, coinciding as it does with the Government working up their end-of-life care strategy, on which they will report later in the year. On that activity, I have this to say: for a long time now, I have been struck by the public sector's selectivity when it comes to consulting people. It is as though it avoids having to listen to anyone who might challenge current orthodoxy or whose superior experience and knowledge might be seen as a threat.
	I share the view of the right reverend Prelate the Bishop of St Albans that it seems odd that the advisory board for the end-of-life strategy includes no one from the hospice movement. I suggest that, at the very least, a senior person from Help the Hospices is invited to join, even at this late stage. After all, between 80 per cent and 85 per cent of palliative care beds are provided by charitable hospices. At St Mary's Hospice, through the provision of in-patient services alone we save the NHS £1 million a year, calculated on the basis of the tariffs it employs. That does not include the round-the-clock, seven-days-a-week telephone advice that we provide. It does not include the daycare. It does not include the numerous add-ons such as complementary therapy.
	On the subject of end-of-life care strategy, might the Minister be able to help me when he comes to speak on behalf of the Government? According to information that I have, there are across the United Kingdom nearly 100 vacancies in palliative care medicine. On the understanding that the new strategy will extend, quite rightly, far beyond cancer, the workload will inevitably increase significantly. I have heard it suggested that it may even double. Will the Minister tell me, or perhaps inform me in writing, what steps he has in mind to address this problem?
	Reading the debate introduced by the noble Baroness, Lady Jay, not long ago—I was very sorry to miss it—I experienced some unease at a number of noble Lords challenging the notion of palliative care going beyond the relief of physical symptoms. There are certainly some add-ons and therapies that we offer in St Mary's which I would be very hard pressed to measure. I do not think that I can improve on the observation made by right reverend Prelate the Bishop of Winchester in that debate, who said:
	"I am not arguing that the effectiveness of palliative care services should not be rigorously assessed and evaluated, but I suggest that in this field, as in many others, there is much that is real, true, describable and important, but not, in the end, measurable".—[Official Report, 31/1/07; col. 311.]
	Albert Einstein put it even more simply:
	"Not everything that matters can be measured and not everything that can be measured matters".
	There is another major stakeholder whose voice is seldom heard—the general public. Of this I feel certain. The general public, certainly in Cumbria, most certainly want the unmeasurables that we provide. In support of that opinion, I ask why else they give such unstinting and loyal financial support. In our case, it is nearly 90 per cent of our total costs.
	I shall highlight just one of these unmeasurables—the bereavement service. This is quite often dismissed as unimportant and low on the scale of priorities. Perhaps there was a time when even I was a sceptic. I now know through our experience that it is hugely important. Put at its most prosaic, it is quite often the only path along which a devastated individual family is able to function and resume normal life. Put another way, at the heart of what we in the hospice movement believe is that not only dying people, but also their families and loved ones, must know that they will not be abandoned to their suffering just when they are most in need. Not infrequently, it is the dying person who needs to know that the family will be looked after in this way.
	At a 30 per cent level of public support for hospices, I venture to suggest that a happy synergy kicks in. Ministers who are faced with an imperative to account for public money can sleep easily in the knowledge that they are getting a bargain deal on core costs of palliative care, and the public get the extras through their local contribution. However, if this is to work, as it can and should, it will entail close co-operation between the public and voluntary sectors. Such co-operation has so far been elusive. Differing cultures present real problems which cannot be wished away.
	Here I come to my second area of optimism. We in Cumbria have a new PCT under new leadership. We are in discussion with this almost brand-new organisation, with a view to establishing what has become known as social enterprise, which would provide the best possible end-of-life care through proper partnership between the hospice movement, the NHS, social services, the voluntary sector and private nursing homes. The PCT has made it clear to us that it believes that our hospice can play a leading role in developing and spreading best practice around individualised patient care. I pay warm tribute to it for this brave and welcome initiative. I believe that it would be the first such enterprise of its kind in the UK and could herald a new era for hospices. It will be a triumph for all participating parties if we can make this work. We are in the very early days of building our partnership, but I have high hopes for it. There appears to be the will among all concerned and on all sides for it to work.
	I would welcome the Minister's comments on rurality—I have touched on it previously. There was a time when, as I remember, financial formulae were in place which were designed to even out the inequities of public service provision which arose out of rurality or remoteness. They have largely been removed with two results: first, providers in rural areas are put under terrible pressure to maintain services and balance their books. The second inevitable consequence is growing rural deprivation. I know that this is a complex subject, and I acknowledge also that common sense dictates that there are trade-offs as a consequence of living in a remote area. However, there should be areas in which there should be no trade-offs and no compromises, and palliative care is one of them. I hope that the Minister will look at this again. If he does not, I fear that he will add in significant degree to the growing problem of rural deprivation and the worsening provision of palliative care in areas such as Cumbria.
	It has been pointed out to me that Eric Cassell, professor of public health at Cornell University, is regarded as one of the greats in contemporary medicine. He has said:
	"The test of a system of medicine should be its adequacy in the face of suffering".
	This short but important Bill seems to echo Cassell's dictum. I support it and wish it safe passage.

Lord Alton of Liverpool: My Lords, my noble friend Lady Finlay of Llandaff has rendered a great service to your Lordships' House by introducing her excellent and timely Bill. I think that we were all moved by the powerful speeches that were made in this debate, and by none more so than those of my noble friends Lady O'Neill of Bengarve and Lady Masham of Ilton, and of the noble Baroness, Lady Gardner of Parkes. I was privileged to meet the late husbands of the noble Baronesses, Lady Masham and Lady Gardner, and I am certain that we were all deeply affected by the experiences which they shared with us today and would want to be associated with the condolences which have already been expressed.
	My noble friend's Bill is urgently needed and the speeches that we have heard have explained why. The UK leads the world in palliative care, but its universal application is compromised because this crucially important service remains underfunded. The Bill is not about assisted dying or euthanasia, which rightly remain entirely outside the scope of this measure. However, as the noble Lord, Lord Colwyn, argued earlier, it provides us with a radical alternative to arguments for the killing of the terminally ill or disabled.
	As my noble friend told us, palliative care is about enhancing quality of life and enabling patients to live as actively as possible until they die naturally, peacefully and, wherever possible, with their families around them. The World Health Organisation describes palliative care as improving,
	"the quality of life of patients and families who face life-threatening illness, by providing pain and symptom relief, spiritual and psychosocial support from diagnosis to the end of life and bereavement".
	By 2031, 23 per cent of the population will be at pensionable age or above, of which 12 per cent will be over the age of 75, in comparison with about 8 per cent at present. As people live longer, the need for palliative care services will clearly increase hugely, and we need to confront the issue now to plan well for the future. That is why the Bill is so timely. It is unacceptable that two-thirds of hospice funding still comes from the voluntary sector. The National Council for Palliative Care has recently released a funding survey which states that around 60 per cent of hospices are experiencing a real-terms decrease in the value of the funding contributions from the National Health Service.
	I know from my own involvement over many years as vice-president of JOSPICE—St Joseph's Hospice Association—that its hospices at Thornton on Merseyside and at Ormskirk in Lancashire, as well as its hospices overseas, run at full capacity. At times, it has been a desperate battle to raise the funds to ensure that they can meet those needs. The quality of palliative care in hospices such as these and all over Britain, as we have heard from all parts of your Lordships' House today, has made huge strides during the past 10 to 20 years, but its quantity and distribution simply have not kept pace. As a result, there is a postcode lottery for the terminally ill, as was said in the preceding speech. Inadequate funding is allotted to palliative care within the NHS and there are not enough trained specialists in practice.
	Three years ago the NHS Cancer Plan promised an extra £50 million a year specifically for specialist palliative care. This addition, made by the Government, is of course extremely welcome but it is thinly spread across the country. Progress is slow and not all the resources are reaching front-line specialists. The National Council for Palliative Care estimates that, while 95 per cent of patients using hospice or palliative care have cancer, 300,000 people with other terminal diseases are excluded. Yet even for those with cancer the provision is far from satisfactory. According to Marie Curie, more than 155,000 people die of cancer every year, yet Help the Hospices points out that there are only 3,250 hospice beds available, and 2,489 of these are supplied by the voluntary sector.
	Half of all patients diagnosed with motor neurone disease—an issue raised powerfully by the noble Lord, Lord MacKenzie of Culkein—die within 14 months of diagnosis. Yet in 2005, the Motor Neurone Disease Association identified that only 39 per cent of these patients were referred to specialist palliative care services. Because hospices have often been funded by cancer charities, some only admit one person with MND at a time and access can be difficult. Is it any wonder that people often become deeply depressed or suicidal when diagnosed with MND, particularly when their fears can be stoked by the pro-euthanasia lobby? Palliative care does not require expensive treatments or technology because its essence lies in specialist knowledge of how to use pain-relieving drugs and how to give holistic care to ease the dying process. A relatively small refocusing of NHS resources would bring disproportionate benefits compared with other branches of medicine. Only a minority of us will need cardiac or neuro surgery but one in two of us will be in need of good palliative care when we die.
	In the recent debate in your Lordships' House initiated by the noble Baroness, Lady Jay, which has been referred to, I was disappointed to read some of the scepticism that was expressed about the holistic nature of palliative care, especially the spiritual aspects—a point touched on at the outset of the debate by my noble friend and by the right reverend Prelate the Bishop of St Albans in his very moving speech. The World Health Organisation description of palliative care that I referred to earlier specifically refers to the spiritual support provided by palliative care and the desirability of providing that support. The importance of this spiritual support is reflected in guidance from NICE. I was interested to read some material from the Association of Hospice and Palliative Care Chaplains on this point, which states:
	"Spiritual Care has always been central to the philosophy and practice of Palliative Care. Palliative Care seeks to be holistic in its approach to its care of persons with life-threatening illness and to integrate the physical, social, psychological and spiritual so that patients and carers may come to terms with their experience of dying as fully and creatively as they are able".
	At a time when fears are being expressed about the marginalisation of faith groups in the delivery of public services, I look forward to receiving the Minister's assurance that the Government, like WHO and NICE, recognise the importance of the spiritual dimension of palliative care and will ensure that this support service is appropriately resourced.
	By extending palliative care to all terminally ill patients, as my noble friend's Bill attempts to do, the Government would save the NHS money. Marie Curie Cancer Care in its Dying at Home report points out that every pound invested in home palliative care services will free up £2 in the NHS. This is an attractive proposition, yet despite increased funding commitments the number of cancer patients dying at home has remained the same—a point made by the noble Baroness, Lady Howe of Idlicote, and others—with 80 per cent of resources allocated to specialist palliative care being allocated to hospital-based care, and that should change.
	A Help the Aged report found that older people are,
	"less likely than younger people to receive support at home, in hospital or in a hospice, or to receive attention from GPs or district nurses during the last year of their lives. Older people are often described as the 'disadvantaged dying'".
	But children are at a disadvantage too. I am a patron of the Zoe's Place Trust, a charity that runs two baby hospices, one in Liverpool, which I helped to establish, and the other in Middlesbrough. There are plans to open a third in the Midlands. When one considers that children's hospices receive only approximately 5 per cent of their funding from official sources whereas adult hospices receive 30 per cent from the same sources, it comes as little surprise that many children's hospices struggle to survive. It costs an average of £2.5 million to run a children's hospice service each year.
	In a joint submission by the Association of Children's Hospices and the Association for Children's Palliative Care, provided for me by St Francis Children's Hospice, Manchester, which I have visited and where I am a patron, it is estimated that 25,000 families in the UK are coping with morbidity of a child, adolescent or young adult. They say that 3,400 children die annually with 80,000 to 100,000 family members affected and requiring palliative care and support. The submission is an excellent document in which they describe their,
	"shared vision of a good life and a good death",
	a point so eloquently expounded upon earlier by the noble Lord, Lord Carlile of Berriew. I commend that submission to Members of your Lordships' House for further study.
	But if holding the line of existing provision is extremely difficult, what of expanding the provision of children's hospices? Hospices such as Zoe's Place are extremely grateful for the £27 million, spread over three years, which the Government have recently made available to them, in the form of so-called Section 64 grants by the Department of Health. But these funds are to help with running costs of existing hospices. What we badly need are more hospices. It is highly desirable that the Government should help with capital costs; for example, by providing matching funds, to enable charities to expand the total provision of hospices, especially for the young. No fundraising is easy, but raising cash to sustain existing premises, which people can see and actually use, is probably easier on the whole than getting support for a project which is still on the drawing board. So what are most needed are the one-off grants to enable new hospices to be built. Comprehensive palliative care legislation should be our priority. I am sure that my noble friend has that right.
	I conclude by addressing an argument that was put by some Members of your Lordships' House today—that a Bill of this nature can quite happily coexist with the legalisation of euthanasia and physician-assisted suicide. We have heard much about patient choice and autonomy in one or two of the speeches. But if personal autonomy becomes a creed, we descend into barbarism. If public reason and statute are to subsist on a diet of choice, autonomy and claimed rights, it will inevitably lead to the emaciation of values which have hitherto underpinned the common good. Hospices and palliative care are surely among the most striking representations of a practical working-out of the common good. My noble friend is therefore absolutely right explicitly to leave out such an approach from the scope of this Bill.
	Far too little consideration is given to the implications of replacing an approach to suffering based on relief with an approach based on the ending of life. What does it do to someone who has a disability or a serious illness if you constantly drip-feed them the lie that they would be better off dead? If, ad nauseam, we persist in telling them that their lives have no value, they will doubtless come to believe it. We rightly hear a lot about dignity, but where is the dignity in an approach predicated on an assumption that your life holds no further worth? Telling someone that they would be better off dead represents a failure in what the noble Lord, Lord Carlile, rightly referred to as our duty to care. "Care" and "kill" cannot be used as synonyms; nor can they be cohabitees, coexisting alongside one another in a hospice established to provide unconditional love, not a lethal injection. It is simply nonsensical to pretend that someone's life has value if you simultaneously insist that their very existence is of negative value.
	This fallacy that autonomy is a superior commodity to all other considerations has profound implications for the way in which we treat the sick. It also has profound implications for those who care for them.

Baroness Emerton: My Lords, I join other noble Lords in congratulating my noble friend Lady Finlay on introducing the Bill, which I support. I declare an interest as a retired nurse, although I am not a specialist in palliative care nursing. My concerns have been raised recently by the vast increase in the public's disquiet about the care of the terminally ill in general hospitals and the community setting. This is supported by Healthcare Commission evidence, to which my noble friend Lady Finlay, referred, that in excess of 54 per cent of complaints received about hospitals show that families received contradictory or confused information from different staff caring for relations. In other complaints, relatives felt that they were unprepared for the death or had no time to arrange for family members to be present. This overwhelmingly confirms the need for an end-of-life care strategy, and I am delighted that a committee under the chairmanship of Professor Michael Richards has been established. Other noble Lords have already referred to this.
	I understand that there are various sub-groups, and although there is no specialist palliative care nurse on the central board, I hope that nursing will be represented on these working groups. I hope that the Minister will be able to reassure me about that, as I am sure he will recognise, as do other noble Lords, that 80 per cent of direct care is delivered by nurses who provide a very important part of the care programme and have much to contribute by observing changes in the condition of the patient through patient contact, in addition to providing direct care.
	Inevitably, the nurse has a close professional relationship with the patient and family, and plays a most important part in carrying out the most intimate care requirements: ensuring that pressure areas are treated to avoid pressure sores, the mouth is kept moist, and nutrition and hydration needs met; monitoring levels of pain and discomfort and treating accordingly; and maintaining the dignity of the patient throughout. Nothing is too basic in holistic care. The care must be holistic; that is, it must meet the physical, mental and spiritual needs of the patient, as stated in the Bill.
	As a student nurse in the introductory course 54 years ago, I remember being told by the tutor—the noble Lord, Lord MacKenzie of Culkein, mentioned the value of good teaching—that holistic care requires not only the direct treatment of physical symptoms but that often there are latent issues affecting the mind or spirit. I was also told that careful observations by the nurse often reveal what these issues are, and that they may be one of the root causes of the patient's discomfort and require attention and even treatment. Likewise, a patient in a terminal stage of illness who is suffering from a physical condition often has a latent psychological or spiritual need that is not immediately manifested, but the need for holistic care by the palliative care team for the patient and family is still vital. It is for these patients that extra time is needed to determine the underlying cause of the problem. The nurse is often the first to pick up the signs because of their major involvement in the treatment of the patient, but this calls for sensitivity and an ethical approach when dealing with often sensitive, personal issues. If the nurse is not able or equipped to deal with the particular situation, they need to refer for help. A team taking a holistic approach values the worth of each member's contribution.
	Dr Christine Kalus, consultant clinical psychologist and chair of the British Psychological Society working party on end-of-life issues states that,
	"the research perspective in relation to the Psychological Dimensions is a relatively new in the specialist Palliative care field but is growing and changing alongside other developments in the general field of health and social care".
	My noble friend Lady Finlay has already mentioned that. The benefits of the specialist being dedicated to taking a "whole person approach" means that researchers can make a variety of research methods both quantitative and qualitative, to approach an exploration of the questions that this complex and challenging field offers.
	Dr Kalus continues:
	"Clinicians are aware that they need not only to take account of the best practice evidence base for their work but also to work as 'scientist practitioners'. That is, to take a systematic approach to their work and treat each situation as a case study. This may take the form of a quantitative inquiry, using standardised measures to ascertain changes in symptoms, pain or it may be using more qualitative approaches such as new methodologies; for example Mckardle and Reason (2006) ... There is also an assessment currently being developed in the UK by clinical psychologists based on work in the US. This assessment is known as the Distress Thermometer ... and it aims to help the individual name and rank their distressing symptoms across a number of domains including spiritual, social, psychological and physical. Once the individual has made a decision about what their most distressing symptoms are the multiprofessional team can work together with the family and the individual where appropriate to try to alleviate/ameliorate those symptoms as far as possible. Preliminary results show that the DT is enabling nursing and medical staff to move into domains that they would previously have found difficult and also to make more appropriate referrals to the relevant other professionals ... It is therefore imperative that psychologically trained practitioners are part of the core multiprofessional team to offer guidance, support and supervision to the staff and also appropriate assessment interventions for the individual patients, their families and following death for the bereaved as appropriate".
	As the noble Lord, Lord Cavendish, has already stated, it is also helpful to remember the words of Albert Einstein, who said that not everything that matters can be measured and not everything that can be measured matters. The Bill also includes the words "social" and "spiritual". Time does not allow me to pursue these, but I must emphasise that both are important, as the right reverend Prelate the Bishop of St Albans so eloquently explained.
	The Bill also sets out regulations and standards. A variety of checks are, of course, already in place. For example, hospices carry out rigorous self-assessment that is then audited by inspection by the Healthcare Commission. The relevant clauses cover patient focus issues, safety, governance, clinical cost-effectiveness and the environment, amounting to 74 pages of detail. However, these checks are only for hospices, not for hospitals or community care in the patient's home. One important factor that cannot be ignored is that the levels of development of pressure sores is very low with good basic nursing care when nurses have time to perform this vital aspect of care. This is not confined to the palliative care patient; the need for such care applies to all patients who are too ill or too weak to move themselves around enough to avoid the risk of pressure sores.
	The Bill would give the Minister powers to create regulations and standards. One hopes that such regulations will be unnecessary if there is a culture change in openness and transparency and in trust between patients' families and team members. Dame Cecily Saunders stated:
	"Palliative Care is not only to help you die peacefully but also to live until you die".
	However, that is not always an easy assignment, certainly not for the patient, for the family or even for the palliative care team. It takes time, energy and commitment to overcome what might seem to be insoluble problems, but they can be overcome with the special attention that they deserve.
	For example, the Royal Marsden Hospital, the largest comprehensive cancer centre in Europe, has a large palliative medicine department. It receives approximately 40,000 new patient referrals a year, and of those the department of palliative medicine sees around 1,200 new patients a year. Its aim is to control pain and distressing physical and psychological symptoms and to discharge the patients to the community services close to their home. Despite its best efforts, approximately 500 patients die in the hospital.
	So-called assisted dying is outside the scope of the Bill, but as the topic has been raised by one or two noble Lords in this Second Reading debate, I will make a comment. Notwithstanding the physical and mental suffering of those patients, the palliative care team of the Royal Marsden reports that less than one patient a year asks for help to die. The palliative care team seeks to address the underlying cause for that request, and over the years of caring for thousands of terminally ill patients, not one has ultimately convinced the team that it was the answer. The director of nursing care of Fair Havens Hospice, Catherine Wood, states that,
	"patients admitted with long term degenerative illness often request that death is aided because they do feel initially repulsed with their body. But good palliative care from an appropriate multi-professional team resulted in the request being withdrawn as improved comfort, quality of life and learning to cope better with their illness have made life more bearable. Every single one of the cases I have personally witnessed has expressed their gratitude to us for not acting upon their original request".
	Surely that demonstrates that patient choice can be addressed. The hallmark of a civilised society is to care for the vulnerable, the mentally ill, the old, the young and the infirm.
	The Bill provides the way forward to deliver appropriate end-of-life care to a standard of excellence that already exists in places such as the Royal Marsden Hospital, including the excellent work of hospices. It is a standard that surely all patients and families deserve and should be able to experience, as so movingly expressed by the noble Baronesses, Lady Gardner of Parkes, Lady Masham and Lady O'Neill.

Lord McColl of Dulwich: My Lords, I, too, congratulate the noble Baroness on introducing this Bill. I also express my deep sympathy for my noble friend Lady Gardner in her loss; I was deeply moved by her courageous speech. I declare an interest as president of the Mildmay centre in east London. I was involved in setting up this first hospice in Europe for people dying of AIDS.
	During the Select Committee chaired by my noble and learned friend Lord Mackay of Clashfern, we had a very useful contribution from Help the Hospices, which stated that,
	"experience of ... pain control is radically different from the promise of pain control, and cessation of pain almost unimaginable if symptom control has been poor. On this view, patients seeking assistance to die without having experienced good symptom control could not be deemed fully informed".
	It is clear that some people have not grasped the important fact that experience of pain control is radically different from the promise of pain control. When one reads some of the speeches on previous debates on the hospice movement, one realises that there are serious misunderstandings about the nature of palliative care. The noble Baroness, Lady Finlay, drew attention to NICE's definition:
	"Palliative care is the active holistic care of patients with advanced progressive illness. Management of pain and other symptoms and provision of psychological, social, spiritual support is paramount".
	I was pleased to see that incorporated in Clause 7 but sad that in our previous debate on palliative care, on 31 January, the Bill was criticised for including,
	"psychological, social and spiritual help",
	which NICE said was paramount. The critic described the inclusion in the Bill as "mission creep".
	The question was asked: how would NHS performance managers measure the efficacy of spiritual intervention? How indeed? As other noble Lords have asked, are we saying that, because we cannot measure something precisely, it cannot be allowed to exist? I hope not. It sounds rather like the language of accountants, who know the cost of everything and the value of nothing. That was stressed by my noble friend Lord Cavendish of Furness, the right reverend Prelate the Bishop of St Albans and the noble Lord, Lord Alton of Liverpool.
	NICE went on to say:
	"Palliative care is part of an overall supportive care, which anyone facing a life-threatening or long-term illness will need at some time".
	Palliative care is often seen as simply offering pain control and symptom control, but if offers a great deal of psychological support in helping people to come to terms with what may have been potentially a devastating diagnosis or piece of news at the end of a process of treatment.
	In the debate on 31 January it was implied that there were patients who did not want palliative care, which includes relief of nausea, vomiting, respiratory distress, pain, intolerable itching, anxiety, insomnia and many other symptoms. Where are the people who want to suffer those symptoms without relief? Perhaps the misunderstanding derives from another statement in the debate that opiate medication caused drowsiness and dry mouth and made patients befuddled, and that some patients forgo pain relief to avoid that. They choose to be alert at the cost of considerable suffering.
	Good palliative care avoids the need to make that choice. Modern drugs in small, precise doses relieve symptoms without knocking the patient out. It was stated that breathlessness, profound wasting, skin breakdown and choking are difficult to relieve, but those are the very symptoms that palliative care concentrates on preventing and relieving. How is that accomplished? As the noble Baroness, Lady Emerton, emphasised, such symptoms are prevented by good—excellent—nursing care. When a patient is dying he is susceptible to thrush in the mouth, called candida because it is a bright white colour. It is easily treated. Dry mouth from drugs, or because the secretions tend to dry up when the circulation of the blood is inadequate, can be effectively managed with good mouth care.
	Anyone who goes to bed for a week—I am sure that all noble Lords have experienced this—tends to develop painful areas. There are six areas to be precise: heels, elbows and the sacral area. If regular attention is not paid to those areas, they can ulcerate and produce a very uncomfortable and painful bedsore. In the good old days, if a patient developed a bedsore the attending nurse had to report to the matron—that was when we had them, and how much we miss them. Pressure sores are a pointer to poor nursing care. They are not an inevitable accompaniment of terminal illness.
	People may have a mistaken view of palliative care because their views are coloured by what happened several decades ago, when pain and other symptoms were poorly relieved by inappropriate doses of morphine, which were only given when the pain had come back with a vengeance. The exhausted patient tended to lapse into semi-coma and then resurface whenever pain returned, only to be greeted by another injection of morphine. As has been mentioned, the speaker on "Thought for the Day" only this morning, who clearly had little knowledge of modern medicine, stated that doctors commonly give patients in pain massive doses of morphine to end their lives. That is outdated medicine of a bygone age.
	The noble Lord, Lord Lester of Herne Hill, raised the doctrine of double effect, which has troubled him for some time. I am grateful to him for confirming that Mr Justice Devlin described double effect in the trial of Dr Bodkin Adams. With all due respect to the learned judge, who eventually became a Member of your Lordships' House, the term "double effect" is most unhelpful. All treatments have a double effect. Penicillin can be given to cure an infection, but it can and occasionally does kill the patient.
	Dr Bodkin Adams was accused of deliberately killing a patient at the end of her life with a large dose of morphine. The jury took exactly 45 minutes to reach their verdict of "not guilty", and rightly so. The chief prosecution witness was asked by the brilliant barrister for the defence whether he could say what would be the effect of giving this large dose of morphine to the patient. The witness said, "Given with intent to kill". The barrister hesitated, there was a long legal pause and shuffling of papers, and asked, "Would you like to reconsider that statement?". "No, quite definitely given with intent to kill". There followed a further shuffling of papers and another long legal pause, and the barrister then said, "Would it interest you to know that the patient received a similar dose three months before, without it killing them?". It later came to light that this expert witness had given a similar dose to a private patient six months earlier.
	Much smaller doses are used nowadays, together with more effective drugs. It is important to emphasise that the dose required to relieve pain is a fraction of the dose required to kill. That, after all, is the definition of a good drug; we call it the therapeutic index. Some have accused doctors of hypocrisy in saying that they are giving morphine to relieve pain when they really know that they will kill the patient. That is quite a false accusation. If, however, the doctor was giving alcohol to relieve pain, that would be hypocrisy; the dose required to relieve pain is the same as that required to kill. So we can bury this confusing and unhelpful doctrine of the double effect.
	As a suggestion, would those noble Lords who harbour doubts about the effectiveness of the hospice movement like to spend a day in a hospice, shadowing staff to see what goes on at first hand? I am sure that they will be surprised at the sensitivity of the care and the serenity of the place, let alone at the high morale and the warmth. That atmosphere is greatly appreciated by patients and families. Noble Lords might find it strange that those who work in an environment of imminent death enjoy their work and are fulfilled as they realise the true value of their vocation.
	I wish the Bill well and congratulate the noble Baroness, Lady Finlay, on this excellent piece of work.

Lord Whitty: My Lords, I support the Bill. I will speak relatively briefly because, despite his vocal incapacity, the noble Lord, Lord Redesdale, has managed to convince me that the Bill is well worth being taken forward by the House. It is one of a series of Private Members' Bills—perhaps a good indication of the importance of the mechanism—that have, either by being directly adopted by Parliament or by influencing government behaviour, made a perhaps small but significant, positive step towards tackling such issues as fuel poverty, energy efficiency and climate change. This Bill is very much in that tradition, and the noble Lord has played a major part in those earlier Bills. I hope that the Government will take most of the points on board in so far as they have not already done so.
	I will declare several interests, just in case they come up. I am a member of the Environment Agency and the London Climate Change Agency, and president of the Combined Heat and Power Association. I also chair the National Consumer Council. As the noble Lord said, if you are looking for sustainable consumer choice, cost at the margins makes a lot of difference. In this area, and in sustainable choices in general, anything that can reduce the cost will guide consumers to make more sensible sustainable choices. This Bill deals mainly with facilitating action and changing the behaviour of householders, farms and small businesses, particularly in improving the energy efficiency of buildings. It also helps to ensure that the property market, both its regulatory framework and its taxation, encourages energy efficiency improvements rather than, as occasionally happens at present, discouraging them.
	The first two clauses are tied up with the argument about home improvement packs. I think I am correct in saying that, seven years ago, I was the first Minister to introduce a Bill—which failed with the recall of the 2001 election—to put home improvement packs in place. It has taken seven years to get there, and there has been considerable turbulence for Ministers in trying to pursue this. I put on record my commendation of the Housing Minister, Yvette Cooper. Whatever else she has encountered in this area, she has maintained a commitment to energy efficiency, which looks as though it will survive and will be a major contribution.
	The Minister also deserves commendation on social housing, where, as the noble Baroness knows, I do not always agree with government policy. Any money that you might squeeze out of the Chancellor in the next spending round—for new-build social housing and replacement of the decent homes initiative—will help to improve the energy efficiency of our building stock. It is important we say that because in the past there has been a trade-off between the ability of units to be produced and the standard of energy efficiency. That is a false economy on behalf of government and future household occupiers.
	Most property is not new; in some cases it has existed for several hundred years. We have the least energy-efficient property stock in northern Europe. The property market is almost entirely about exchanges on existing property. As the noble Lord, Lord Redesdale, said, over 25 per cent of carbon emissions emanate from the building stock. It is important that we require in the buying and selling process that greater attention is paid to energy efficiency provisions. Under the HIP provisions we will set different prices for equivalent buildings on the grounds of relative energy efficiency. It may be relatively marginal to start with, but it will become a significant part of how people negotiate the price of a building, in terms of premium, on the one hand, and discount, on the other—and in last-minute deals on a house.
	I regret that, when I took part recently in debates on the Consumers, Estate Agents and Redress Bill, I failed to notice the need for a requirement, in quasi-regulation under that Bill, that estate agents ensure that all their advertising meets the kind of provisions that the noble Lord has put into this Bill. That may have been another way in, but it is here in this Bill and we should endorse it.
	As the noble Lord, Lord Redesdale, indicated, since the Bill was first presented, the Government have moved some way towards stating that they will regulate in the context of HIP roughly what is contained in the first two clauses. I would very much welcome confirmation of that from the Minister. I hope that that would ensure that the provisions of Clause 2 would be dealt with in legislation passing through another place, or in other ways. If we were to remove our attention from those two clauses, and if the Government were unable to use other provisions, we would be missing an opportunity.
	Another issue is how we fund the market. Mortgage providers fund the bulk of the property market, both domestic and commercial. It is important that, given the many options available to mortgage seekers of all kinds and the creativity of the financial sector in this area, which has been positively remarked upon, we should consider requiring that energy efficiency improvement be offered on mortgage-like terms, with long pay-back periods and mortgage-related interest rates. Whether they should be called "green mortgages", with all the complications to which the noble Lord has referred, is immaterial; but there is scope for placing a mandatory requirement on mortgage providers to offer some kind of option. After all, the contribution of the financial sector to sustainable objectives has not been remarkable. It is an area where mortgage providers and banks could make a significant contribution.
	The other aspect of any market is taxation, and the provisions on council tax are important here. There are some very good but localised examples of individual councils making positive provision through a council tax discount against improvements for energy efficiency or fuel poverty elimination. I would prefer to see a big push on that front, but it is also true that a number of provisions, which both domestic and commercial operations have adopted, have led to an enhanced council tax band or enhanced business rates. That is perverse; the Bill has a fairly minimalist objective: to avoid the discouragement of desirable energy efficiency measures by the council tax system. I hope that the Government, including the DCLG in its arguments with the Treasury in this area—it is responsible for local taxation—will ensure that we avoid this perverse effect.
	In addition to householders and small businesses, the Bill would benefit farmers. Most people tend to think that farmers' contributions on energy supply are largely through growing biofuels, of which I am an important advocate. They can also make a major contribution by having small-scale generation on their land. I am very much in favour of the commitment in the recent energy White Paper to use decentralised energy; I refer to their, and their near neighbours' use on-farm and to selling that energy back to the grid. We are talking not about huge turbines here, which involve landscape objections, but small-scale wind turbines, solar power, CHP on-site and so on, all of which could make a significant contribution. That provision is an important part of this Bill; it could save farmers money and give them some much-needed income.
	All aspects of this Bill should be acceptable to the Government; they are much in line with aspects of the energy White Paper and the Government's desire to encourage more sustainable behaviour among consumers. Taken with the measures that the Government have already embarked on, they could make a major contribution to the efforts of householders and owners and occupiers of buildings to tackle climate change. I therefore commend the noble Lord, Lord Redesdale, on bringing this Bill forward and I hope that the House can accept it.

Lord Watson of Invergowrie: My Lords, I, too, should declare an interest at the outset as a past president of Energy Action Scotland. I continue to support that highly respected and very effective organisation. I also congratulate the noble Lord, Lord Redesdale, on promoting this Bill, which I support. I very much hope that it will have a smooth passage through the legislative process. Although the noble Lord did not specifically refer to this in his opening speech, the Bill in my view builds on the Climate Change and Sustainable Energy Act 2006. That excellent piece of legislation was introduced by Mark Lazarowicz in another place in 2005. It enjoyed enthusiastic cross-party support during its consideration, which was widely welcomed as a sign that the Government were serious about the need to ensure that microgeneration makes a contribution to their energy and climate change targets.
	Microgeneration or micro-power could be described as involving small-scale renewable low-carbon-source energy technologies. It can play an important role in this country's contribution to combating the effects of climate change. It will increasingly have the additional benefit of reducing the transmission capacity requirement of the national grid and may in the longer term obviate the need for investment in large new power stations.
	One factor in increasing the proportion of this country's energy that is generated by renewable sources is convincing people that they, as individuals, can be supporting actors in what is not just a big picture but the all-time blockbuster. Those who attempt to downplay climate change or even, in extreme cases, to deny its very existence—there still are some—are the modern-day flat-earthers. Thankfully, their voices are becoming ever fainter as the evidence against them mounts. The question is not, "Do we need to act?" but "How quickly do we need to act?". Public opinion in the UK does not ask what the problem is; it asks what we can do to reduce and, ultimately, overcome it. Microgeneration is a realistic means of responding to that question, although much more prosaic actions can be undertaken.
	Many noble Lords will have seen this week's full-page newspaper advertisements by the Energy Saving Trust as part of its "Save your 20 per cent" campaign, in which it highlighted doing things such as turning off the TV standby and using energy-saving light bulbs and loft insulation. As the noble Lord, Lord Redesdale, rightly said, any family can implement such actions immediately—with, I suppose, the exception in the last case of most flat dwellers.
	Thereafter, many people genuinely want to do more to directly lower their own carbon output. That is why the encouragement offered by schemes such as the low carbon buildings programme and its Scottish equivalent—the community and household renewables initiative—are so important. Both provide grants for householders and community projects, as well as builders and developers, to support the installation of large microgeneration technologies.
	These schemes are increasingly successful, but significant barriers remain to be overcome if the uptake of microgeneration and energy efficiency is to be increased. I think that it is fair to say that, historically, the major constraint has concerned a lack of information about the products available, allied to concerns about their quality and reliability and the length of the payback involved. I should be interested to hear the comments of the noble Lord, Lord Redesdale, on payback. I put the question to him, in particular, because he gave the example of his kitchen, but he did not say whether he was to pay back his wife or whether his wife was to pay back him and, if so, whether it was to be a financial transaction. Perhaps he will tell us when he addresses the House again.
	Payback is an issue in relation to these schemes, but cost cannot be put to one side, not least due to the fact that new products with an initially low demand are often expensive. To that end, the announcement by the Chancellor of the Exchequer in the 2006 Pre-Budget Report that the sale of surplus electricity from installations designed for personal use would not be subject to income tax is much to be welcomed. However, for that to become fully effective, I believe that a third barrier—the lack of suitable meters to record and evaluate micro-producers who may want to export excess power to the grid—must be addressed.
	A further disincentive has been the requirement for planning permission for some forms of microgeneration. The 2006 Act charged the Government with responsibility for reviewing the current regime concerning planning permission requirements for micro-technologies. I hope that that will be brought to a swift conclusion, followed by the implementation of effective changes. That said, local authorities that have a policy of encouraging such developments can already act in a manner that will facilitate their introduction.
	As an example, I draw the House's attention to the City of Edinburgh Council, which wants to encourage its citizens to install solar water heaters and is in the process of making such applications exempt from the permitted development regulations. At present, applying for planning permission can add £300 to £400 to the cost and can mean a delay of several months, neither of which is likely to act as an incentive to householders. I am sure that other local authorities will be seeking their own way to remove such obstacles to the development of microgeneration, but the sooner the Government produce conclusions to their own review, the better.
	Clause 4 of the Bill refers to the need to facilitate the development of microgeneration on agricultural land, and I can well appreciate the noble Lord's reason for highlighting this need, particularly as he outlined his own recent experiences. That was not specified in the 2006 Act, and there must be a great deal of scope for utilising microgeneration technologies in the agricultural context in ways that would not just contribute to the overall need to reduce carbon emissions but also provide cheaper and more efficient forms of heat and power in rural areas.
	There is a tendency by those of us who live in urban areas to assume that anyone who wants a gas supply at their home can have it. But, of course, that is not the case. In fact, it is probably not widely known that around 30 per cent of homes in Scotland are off the mains gas grid and are never likely to be connected to it. I am sure that some rural areas in England will not have access to gas supply either, and I imagine that that will particularly be the case in respect of agricultural land. Quite apart from issues relating to carbon emissions, research undertaken by the Fuel Poverty Advisory Group shows that the most effective measure for removing a household from fuel poverty is to fit a gas central heating system. Where that is impossible, other measures become increasingly important, which is an additional reason why this clause should be welcomed.
	I am particularly supportive of the clauses that seek to build into legislation measures that will increase awareness of what is termed the "energy rating" of a property. Not only will a prospective purchaser of a home who is conscious of energy efficiency have the ability to make a fully informed assessment of the overall quality of the property but the fact that estate agents will be required to bring this important issue to the general attention of all prospective purchasers will be of considerable value. Irrespective of whether they had hitherto placed energy efficiency within their criteria when deciding on the suitability or otherwise of a property for purchase, I believe that the fact that this information is up front in the particulars—as the noble Lord, Lord Redesdale, described it, from the small print to the large print—will reinforce its importance.
	Earlier this week, the Scottish Parliament somewhat controversially voted to introduce a single seller property survey. This means that the seller of a property will be responsible for producing the information necessary fully to inform potential buyers—a move opposed by the Law Society of Scotland. The kind of information outlined in Clause 1 of this Bill could usefully be included in that Scottish single seller survey. I hope that the passage of this Bill will encourage that to happen, because I firmly believe that such information should increasingly be regarded as essential when a property is being purchased.
	I also welcome the fact that notices to be displayed by estate agents will be required to make explicit reference to the value of energy efficiency and microgeneration. Fuel poverty is a major issue and, apart from through gas central heating, it can be reduced by the relatively inexpensive use of basic energy efficient practices, such as loft and cavity wall insulation, as has been said. It would be a mistake to assume that fuel poverty affects only the poorest families. The accepted definition of fuel poverty is a household where more than 10 per cent of its income is spent on heating. Home owners often fall within that bracket, particularly at times of high fuel prices, such as we have been subjected to over the past two years. It is self-evident that any measures that people have not previously used to minimise their energy bills have to be of considerable value, and the more that such measures are highlighted, such as those suggested in this Bill, the better.
	Other clauses in the Bill also serve to emphasise the need for the growing importance of microgeneration technologies to be more widely recognised. One of the main considerations of fitting, say, a small domestic wind turbine is that the price could be in the region of £1,500, not including the cost of the planning application. With even the upper end of estimates for the consequent annual saving on fuel bills unlikely to exceed 10 per cent of that cost, that suggests a considerable payback time—very probably longer than the individual intends to retain ownership of the property. Thus any measure that ensures that an increase in the value of the property consequent on the installation of a microgeneration system does not have the knock-on effect of pushing the council tax payment into the next band is desirable. The noble Lord, Lord Whitty, called it the perverse effect. I very much agree with that and I hope that the Government will find a means of avoiding it so that it does not act as a disincentive.
	Equally, when a householder wants to introduce some form of micro-power as supplementary energy generation, knowing that there is a ready source of funding to facilitate it will be a considerable comfort. The noble Lord, Lord Redesdale, accorded that a plan for green mortgages—I am attracted to that terminology—but I should have thought it likely that, as the value of the property should increase, most banks or building societies would be willing to provide lending. Clause 5 of the Bill guarantees that, which could play an important part in convincing individuals to proceed with some form of microgeneration.
	In conclusion, I believe that the Bill deserves to meet with widespread support, and I very much hope that it will. It will enhance the major advances contained in the Climate Change and Sustainable Energy Act and encourage more people to make their own contribution to reducing carbon emissions, tackling fuel poverty and ultimately reducing demands on the national grid. I look forward to the Minister signifying government support for the thrust of this Bill. Once again, I congratulate the noble Lord, Lord Redesdale, on having the foresight to bring it forward.

Lord Teverson: My Lords, I, too, thank and congratulate my noble friend Lord Redesdale on introducing the Bill. It is funny how in these debates you often find out things about Members from opposite sides. On this occasion, I found out something about noble friends. It seems that everybody on the Liberal Democrat Benches is having their kitchens redone. I do not have a question about the pay-back period in this area. My concern is that, as we speak, my ceiling is being taken out, and I wonder whether I will be able to eat at all this weekend. Perhaps I will have to come back quickly to the Members' Dining Room on Monday, but we will see about that.
	The key thing about this Bill is that it brings the issues down to individuals and individual households. I have recently been to a number of small-scale showings of Al Gore's "An Inconvenient Truth". The reaction at the end of that presentation is one of "What we can do as individuals?". Too often with global warming and climate change, we are intimidated by the problem being so large, long-term and seemingly intractable that we wonder what we can do about it as individuals. Then we remember that the United Kingdom is only responsible for some 2 per cent of carbon emissions, the EU 13 per cent and so on. The problem is elsewhere, but there is a great wish by individuals who are increasingly coming to recognise the problem, as noble Lords have said, to take some action themselves. The Bill shows how that can start to happen on an individual basis.
	From the Government's point of view, there are only a limited number of ways in which this can be done, and the Bill reflects some of them. One, as we know, is green taxation, carbon emissions trading and the pricing side of things. Again, the Bill brings pricing or charging down to the household level, in that it makes a statement that by improving our energy efficiency or producing energy ourselves, we are not penalised by increasing council taxation on our own properties. It has that ticked.
	We have a positive in that the Bill does not add regulation, but removes some on planning issues, particularly in agriculture; again, we have a tick. Information is important in keeping people onside and maintaining their enthusiasm for and recognition of these issues. That conveniently ties in with other areas of government legislation, such as that on estate agents and household information packs, a critical area tying in with the good will and wishes of those concerned about these issues to do this in a practical way.
	There is another important area. I have recently moved to a hill by the coast in Cornwall. There is no better place, other than many in Scotland, to maximise wind energy. We have looked at wind generation with a 6.5 kilowatt generator on our property, which is technically feasible. When we look at the capital cost, however—something like £21,000—it is a lot of money for any household. Although we talk about payback, which is important, there are a number of other important items of household expenditure. Even in an area with a high level of wind energy, our payback is estimated to be something like 12 years.
	As the noble Lord, Lord Whitty, has pointed out, financial service businesses and lenders have not been pro-active in terms of householders and consumers being able to get the cash flow for micro-energy. It would clearly be best if the savings made were equal to future loan repayments, but the financial markets do not quite work in that way. There is a clause in the Bill of the noble Lord, Lord Redesdale, reflecting affordability and cash flow.
	The Government have important targets on cutting carbon emissions. Unlocking the potential of individuals, households and families to help those targets is very important within a national and global context. On behalf of the Liberal Democrat Benches, I therefore welcome the Bill, as have other noble Lords who have already spoken. I recommend that the Government take the Bill though both Houses; it is complementary to the Climate Change Bill we expect later in this Session.

Lord Taylor of Holbeach: My Lords, I, too, congratulate the noble Lord, Lord Redesdale, on enabling this interesting debate on appropriate carrot-and-stick incentives—more carrot than stick—to improve energy efficiency and encourage the use of microgeneration. He can be assured that the message in his speech opening this Second Reading debate was robustly delivered despite his croaky throat.
	I should tell the House that, some time ago, I investigated the possibility of emulating a number of my Dutch friends by looking at the economics of installing a wind generator in my drafty part of the Fens, much like the noble Lord, Lord Teverson. At that time, it was not a feasible proposition, and I regret to say that I doubt it would be one now, but to the extent that I have an interest, I should declare it. I am also one of the people referred to by the noble Lord, Lord Watson, who have no access to mains gas, despite the fact that the Bacton gas line goes through our farm. Not surprisingly, I have maintained my interest in the subject.
	A consensus is building fast that man-made climate change is one of the greatest environmental challenges faced today. Its consequences are not just environmental; they are also economic. The noble Lord, Lord Watson, rightly drew attention to that. Advocates of ecological modernisation are right to highlight that environmental policies can help boost the economy, create new jobs and stimulate revenue streams. Microrenewables are an example of that. They are part of a high-tech, value-added sector in which we as a nation could excel. They are right up our street, one might say.
	Indeed, it is easy to argue that the Government should be leading by example in this area. I was pleased that the microgeneration strategy that the DTI published last year suggested that:
	"Government departments are in a good position to lead the way through demonstration of these technologies".
	However, I have been disappointed that the only promised action is for the DTI actively to investigate the possibilities for microgeneration on its estate. With the Government publicly committed to a number of building programmes, such as community hospitals and prisons, can the Minister inform the House about what progress has been made in the past 11 months to deliver that commitment? Do the rules of the private finance initiative include provision for microgeneration in association with projects? How seriously are agencies, public bodies and government departments taking centre stage in developing exemplars? I hope that the Minister will be able to commit to a review of progress in this area that can be reported to the House.
	Very little that is put forward in the Bill is new or dramatically original, but I shall take the opportunity afforded by this debate to press the Minister on some of the issues. The noble Lord, Lord Redesdale, is rightly pleased with the outcome of his proposals in Clauses 1 and 2, which consider the energy rating of property. I am sure the Minister will highlight the EU directive on energy performance, which will require us to produce an energy performance certificate whenever a building is constructed, sold or rented out. From June, it will be an essential part of home information packs in which sellers prepare key information before they put a property on the market. I shall not reiterate our view of home information packs because the House knows it well. The noble Lord, Lord Whitty, spoke eloquently in their favour. How many inspectors will be fully trained to deal with property sales after 1 June, and how many will be needed to carry out the anticipated workload? Is there a contingency plan in case there are not enough trained inspectors? Have Her Majesty's Government made an assessment of what failure—for a failure I expect it to be, unless the Minister can surprise the House—might do to property sales? These are the questions that we should be asking, not whether an estate agent should be compelled to make generic statements on his literature.
	As the noble Lord, Lord Redesdale, said, more than 25 per cent of UK carbon emissions come from domestic housing, and the Government are committed to a 60 per cent cut in emissions by 2050. Encouraging domestic home owners to save energy is a logical step. Yet, it has been put to me by outside organisations that the current approach to renewables, especially microgeneration, while well meaning, is a combination of underfunding and mismanagement as well as a lack of appreciation of the impact these projects can have on the real world.
	So, let us consider what the Government have done. The low carbon buildings programme—LCBP—is the Government's principal mechanism to deliver their policy to expand the use of microrenewables. It issues grants for householders seeking to install microrenewables. However, the DTI's cap on monthly allocations has meant that the total grant for this month—£0.5 million—was allocated within just 12 hours of it becoming available. That does not seem inductive of encouraging home owners to "go green". Indeed, the REA and trade associations have argued that it is killing demand. What assessment have Her Majesty's Government made of whether this system is indeed adequate or efficient? Have they considered calls for the removal of the cap, which some suggest presents uncertainty to the industry and its customers?
	If you are one of the successful few who are given a grant under the LCPB, how successful is it? There was an article in the Times of 17 February which claimed that urban turbines were a,
	"load of huff for very little puff".
	Having spent £13,000 on installing a wind turbine in his urban home, a Mr Large was disappointed that the return on his investment amounted to only 9p a week. The noble Lords on the Liberal Democratic Benches might expect a better return than that from their kitchen investment.
	Part of the problem was that the turbine puts power directly into the national grid, but the requirements of the grid mean that power can only start being transferred once the blades have been turning fast enough for several minutes non stop. That highlights that some of the attraction of microrenewables is that, as a consumer/producer has less need to buy electricity, they can make money by selling any excess electricity back to the national grid. However, that is being made far too difficult by an inadequate infrastructure and burdensome regulations. What assessment have Her Majesty's Government made of the current operation of the national grid, and how well is it configured for two-way energy flows from many small households?
	Has the Minister given consideration to the fixed-feed tariffs that are the primary support instrument for renewable energy throughout Europe? Under that system, a fixed price is paid for the renewable energy, usually with different price levels set for different technologies. These prices are linked to market penetration and development of any market. For example, elsewhere PV's current fixed-feed tariff rates range from €15 to €62 per kWh. That seems to have successfully encouraged a range of renewables to come through under the renewables obligation, not just onshore wind as in our case.
	Clause 3 raises the issue of value in relation to domestic households. It is interesting that if you get an organisation to install your system, you pay a lower rate of VAT than if you bought in all the parts and installed it yourself. That is certainly inconsistent, and I would be interested to hear the thoughts of the Minister on that situation. While the noble Lord, Lord Redesdale, has discussed the impact of home improvement in terms of council tax valuation, I would like to touch on the effect that investing in renewable energy can have on business rates.
	What assessment have the Government made of the potential impact on small and medium-sized businesses, whose rates may increase as a direct consequence of green investment? I understand that there may be a disparity between combined heat and power, which is partially exempt from business rates, and zero-carbon renewables, which are not. I hope that the Minister can clarify that point in her reply.
	I am conscious of the time. We have been a happy if small band this afternoon, but it is clear to all of us that there is much to do both on individual and business levels. We need to look carefully at the working and implementation of the incentives currently available.
	The noble Lord, Lord Redesdale, has done the subject a great service by bringing his Bill to the House. I hope that I do not disappoint him when I say that we do not agree with all of his proposals, but we support the opportunity for debate and I hope that the Minister will use it to respond to the issues and questions raised.

Baroness Andrews: My Lords, we have had an interesting and enjoyable debate. I am sure that the noble Lord, Lord Redesdale, will have some of the answers to many of the questions raised. I shall do my best to answer them from the Government's point of view.
	It has been a heroic debate, not least because the noble Lord is struggling with a sore throat. I hope that he is feeling better because of the warmth of support that he has received from around the House. We have also had a diversion into domestic arrangements. I can join the debate on new kitchens: I have just finished one. I have no idea when I can look forward to payback; in fact, I have almost given up already on any return.
	This is a very serious debate. I commend the noble Lord for his ingenuity and imagination, as well as his commitment to raising, and enabling us to address, such important issues. Noble Lords have already anticipated much of my reply. Although we are extremely sympathetic to the intention of the Bill, as many noble Lords have pointed out, I am going to say that the Government are doing much of what is in it; indeed, we are going further. I am especially glad to have the company of my noble friend Lord Whitty, with his long history not least in the development of the home improvement packs. He is now taking his expertise into other areas.
	We are well aware that the improvement of energy efficiency in housing stock is a fundamental battle against climate change. I understand that 27 per cent of carbon emissions come from homes, which account for a significant amount of the roughly half—47 per cent—of carbon emissions overall that come from buildings in general. We are right to want to draw those figures to the attention of every householder. We have had the beginnings of a very interesting debate about the nature of the public response at present and the aspiration that individuals are showing to take the matter into their own hands and do what they can, even in sometimes unglamorous ways, to address the problem. We are as one in recognising that microgeneration equipment has a crucial role to play in enabling us to do that and to reduce carbon emissions.
	I shall describe how much of the Bill is covered by anticipated changes in regulation and so on and by our work across the whole field of microgeneration in response to climate change. I am sorry to say that we do not believe that primary legislation is required at present.
	I shall also say a few words, although I am very grateful for the noble Lord's restraint, about home information packs. I quite appreciate the division that exists between us in the House. We believe that home information packs will make a significant contribution to making the buying and selling of homes more rational, transparent, better informed and more effective for consumers, but this is an opportunity to bring noble Lords up to date before I address the Bill. I am very grateful for noble Lords' support for home improvement packs, particularly for energy performance certificates, which are a crucial part.
	Last month, we published a home information packs update that outlined our plans for finalising the introduction. I assure the noble Lord, Lord Redesdale, that, despite continuing criticism—much of which is from people who have never been sympathetic to what we are trying to do—we will definitely introduce home information packs on 1 June and will lay regulations next month. That is part of the process. Last month's update reflects our commitment to react to information coming in from the area trials and provides information on areas of policy that have been adjusted in response to such information.
	In particular, we propose changing the policy on the timing of the provision of searches and leasehold documents because they have proved to be sticking points in some areas during the trials. So we are responding to concerns. We now require that searches and leasehold documents are commissioned before the property goes on the market, which will eliminate the problem of preventing homes from being marketed quickly, while still reducing delays in the current system when these documents are not requested until after an offer has been accepted. In addition, we have also proposed making the provision of energy performance information in the packs more robust, which I will come to when I address the provisions in the Bill.
	In November, the first phase of the area trials got under way in six regions and we have adjusted our policy in response to that. In the past couple of weeks, those trials have moved to two new areas in London and north-west Wales. As we have made clear, these trials will also be subject to independent scrutiny, and we look forward to examining the results of that research as the roll-out of HIPs moves on. We also published the baseline research last month, which supports our view that the measures, when implemented, will improve the home-buying system in the way that I have described. The noble Lord, Lord Redesdale, mentioned curtilage, which I will come to when I talk about Clause 4.
	All noble Lords picked up on Clauses 1 and 2. This legislation would require that home information packs should include prominent information about the energy rating of the property. The noble Lord and I agree entirely about its importance. Of course, it will become increasingly important, which is why from 1 June all sellers will have to have an up-to-date energy performance certificate in their HIP before they put the property on the market. As the noble Lord, Lord Taylor of Holbeach, said, this is a requirement of the European energy performance of buildings directive and is a very important first step in the implementation of the directive. As we move towards January 2009 we will extend those duties to provide EPCs to include sale and rental of commercial buildings, and the rental of domestic properties. They will also be required on construction of all buildings. Public buildings and large buildings with public access will be required to display certificates that indicate how well the building is performing year on year.
	Not only will we provide what the noble Lord is asking for, but we will go further. Perhaps I may explain why. The noble Lord's Bill would require that energy ratings appear prominently in HIPs; but under our regulations not only the rating but also a full energy performance certificate, including important recommendations about how to improve the energy efficiency of the property, will be included. As we finalise what these might look like, I would be very happy to share that with noble Lords. In response to the noble Lord's query, of course my officials would be delighted to meet him to talk about the issues that he has raised on the Bill.
	The EPC will be prominent in the pack because it will be the first document and will be extremely visible; therefore, buyers are bound to be aware of the information contained. It will enable sellers to improve energy efficiency, and they would be advised about how that might be achieved. We all know how new owners set about altering properties after they move in, and this extremely important and useful document will inform them how they can make energy efficiency improvements.
	It will also enable owners to save money on their fuel bills, a point raised by my noble friend Lord Whitty. Several noble Lords addressed the issue of rising costs, and the Energy Saving Trust (EST) has shown that the average property owner will be able to save about £300 a year on energy bills if they follow the low-cost recommendations on their energy performance certificates. Anything that influences people to make positive decisions and choices is important. As my noble friend Lord Whitty said, price will do that. So that is all very good news about how we are facing up to the challenge of reducing carbon footprints.
	We are going with the grain of what people want. An independent survey of customers suggests that 75 per cent think that the EPC is a good idea. So, again, the proposal is extremely well intentioned but there is no need for primary legislation.
	On Clause 2, how will we ensure that the documentation produced is included in marketing the property? Again, we are in full agreement on this. It is important that this should apply not only to houses but to the contents of houses; we need to know where energy is being used, whether by fridges, cars or houses. This level of awareness is crucial as we attend to the pressures and speed of climate change.
	This is why in the HIPs update, to which I referred earlier, we have proposed that the details of the energy performance certificate should be attached to written particulars by estate agents. I am sure noble Lords will agree that, if we do this, we will have to make it practical and proportionate as well as informative. That is why we are consulting on the proposal, and the final decisions will be based on the results of consultation on the HIPs update. We are looking at ways to make the information as visible and accessible to consumers as possible while being consistent with the principles of energy efficiency. We do not want to end up printing reams of paper. It is an iterative process and how we deliver it through estate agents' advertising material will be informed by the views of the industry.
	The noble Lord, Lord Taylor of Holbeach, asked about the number of inspectors. We are confident that there will be sufficient home inspectors and domestic energy assessors to meet the requirements of the market. Our constant discussions with stakeholders suggest that there is very high interest, particularly in the DEA qualification. Two awarding bodies have already had their DEA qualifications approved and another is close to receiving approval. We are demonstrating what we expect in a series of road shows and, as EPCs are extended to buildings for rent and sale and to all buildings, there will be an increase in demand. We estimate that there will be a need for between 1,600 and 4,300 inspectors for mandatory EPCs and voluntary HCRs for HIPs. At the moment we have 290 qualified home inspectors who can produce both and a further 1,100 still in training who have already completed enough of their course to be able to qualify by 1 June. Details of the DEA qualification can be found on the websites of the awarding bodies. Perhaps it will be useful if I write to the noble Lord with the information that he requested.
	Clause 3 is very important in relation to council tax. We are entirely at one with the suggestion that there should not be any disincentives to people from improving the energy efficiency of their home. We endorse that wholeheartedly. It again provides an opportunity to refer to the HIPs update document, which repeats the Government's support for locally run incentive schemes such as the one piloted in Brentford, which encourages home owners to improve the energy performance of their houses. We expect the EPCs to encourage home owners and home buyers to improve their domestic energy performance.
	I want to make it clear to all noble Lords who have raised the issue that home owners installing energy-efficiency equipment will not see their council tax bills rise as a result. First, any change or improvements to a property that increase its value cannot result in a higher council tax band until the property is sold or any future evaluation of properties takes place, but even then the width of the banding system, which is very generous, means that only an improvement that significantly increases the value of a property is likely to push it into a higher band. It is therefore very unlikely that installing microgeneration equipment or energy-efficiency measures will affect the banding of the building, so we do not see that there will be much scope for these perverse effects.
	On the question asked by the noble Lord, Lord Taylor, about the non-domestic rates, the Valuation Office Agency similarly advised that installing microgeneration equipment might lead to no change, or a negligible one, in a business property's rateable value, and hence the rates bill. Obviously the valuation officer would reassess the rateable value of the property at the time the equipment was installed and measure the effect on the rental value, but that is the best evidence we have had from the VOA. We have to remember, with regard to some of the other questions the noble Lord raised about the nature of the technology, that this is new technology. There is at present no evidence available to the Valuation Office Agency regarding, for example, the development of a two-tier market for commercial buildings with or without microgeneration equipment in the way that there is for buildings with or without heating. Again, we will have to wait and see and use our best intelligence to gauge how that might operate.
	I shall pick up some of the other questions on Clause 4 and the whole business of planning and microgeneration, an issue close to the heart of government policy. This might be the point at which I should address one more question from the noble Lord, Lord Taylor, on the business of the Government giving a lead on microgeneration in terms of its own stock. He is right that in June 2006, following the microgeneration survey, the Government set an aspirational target to reduce carbon emissions from central government buildings by 30 per cent by 2020. In fact, we have committed to making the central government estate carbon neutral by 2012, so we will be working with that challenging target in mind.
	I return to Clause 4. Our planning system does and should help to shape places with lower carbon emissions, places that are resilient to climate change. Our ability to respond to those challenges—the way we live and where we live—will pose new challenges to the planning system. That ability to respond properly will be at the heart of what we expect from good planning. Again, we have anticipated much of what the noble Lord wants. However, the microgeneration strategy in March 2006 identified that the installation of microgeneration equipment is currently constrained by uncertainty over its planning status, inconsistent treatment by local planning authorities and the costs and time involved in obtaining planning permission.
	We said in that strategy that we are committed to reviewing whether we should do anything further to facilitate the installation of microgeneration through the planning system, particularly through local plans and for householders. We followed that up on the two relevant fronts; first, through planning policy itself, and secondly through committed development rights. We issued a Ministerial Statement in 2004 that built on the existing planning policy statement on renewable energy, PPS 22, issued in 2004, which noble Lords will know is the core of our planning arrangements in terms of building renewable energies into our planning policies at spatial and local level.
	We have launched a public consultation on a new draft planning policy statement on climate change. We have carried out a review of permitted development rights for householders. I want to say a little bit about the chronology of what we have done in those two respects. We in the DCLG have worked closely with the DTI, and we continue to do so. The basis for our approach in the report, set out in PPS 22, has made it clear that planning bodies are expected to identify in their broad areas where developments of particular types of renewable energy may be considered appropriate. Areas in agricultural use will be considered as part of that process. On 8 June 2006 Yvette Cooper issued a Written Ministerial Statement, sent to every planning authority in England, reminding them of that guidance, urging them to take advantage of it and making clear that all planning authorities are now expected to include policies in their development plans which require a percentage of the energy for new developments to come from onsite renewables, where that is viable. That is an extremely important tool.
	Just before Christmas, we issued the draft planning policy statement on planning and climate change, which is currently the subject of consultation. That complements PPS22 and the statement, and makes it unequivocally clear that planning is a positive force for change. It includes strong expectations at regional and local level that low-carbon technologies must be properly planned for.
	Finally, and most important, we have been reviewing whether permitted development rights should be extended to domestic microgeneration equipment in accordance with Clause 10 of the Climate Change and Sustainable Energy Act 2006, to which the noble Lord, Lord Taylor, referred. We are aware of the size of the challenge and want to see as much innovation as possible.
	Following our review, we have been working out proposals for extending permitted development rights for householders to install certified categories of equipment without the need for planning permission. Given what noble Lords have said about their valiant efforts, it seems that everyone who has spoken is living in a particularly windy part of the country. We will shortly be issuing public consultations on those proposals and will look forward to your Lordships' responses.
	That is the context in which we are considering the Bill. On the implications of this clause, I should like to mention the further action recommended by Kate Barker in her recent review of land-use planning, published in December 2006. She proposed that, to help to combat climate change, permitted development rights for the installation of microgeneration equipment should be further extended to other uses beside domestic. She specifically mentioned commercial uses, and we will want to consider the scope for including agriculture in our response to this proposal. We will make our intentions clear when we bring forward our planning reform White Paper.
	Encouraging the take-up of microgeneration through a clearer planning framework will help us to meet a significant proportion of our future energy needs. When we talk about extending permitted development rights, whether domestic or otherwise, we must not disregard our responsibility to protect neighbours, the wider community and the environment from adverse effects such as noise vibration. We must have a serious regard for that. Therefore, our proposals will be based on careful assessment of impacts. Any extension of permitted development that we consider will also use that approach and be subject to full consultation.
	On the specific point of curtilage, I agree that there is potential for agricultural land near to housing to meet domestic needs. We are seeing more of this but it generally requires planning permission. It is quite difficult in some areas to install even small turbines on agricultural land without planning permission. We would be happy to discuss this further with noble Lords.
	The noble Lord, Lord Taylor, asked about the low carbon buildings programme. Together with the £45 million committed under the previous clear skies and solar PV major demonstration programme, it will give an anticipated £125 million in support of the industry by 2009. I cannot answer the specific question about assessment but I would be happy to write to him about that and about his rather technical questions about the national grid. However, the noble Lord, Lord Redesdale, may have fuller and more detailed responses for him.
	While we cannot change planning matters overnight, I believe that in the period since 2004 we have moved very swiftly to address these issues and to take advantage of the potential. We intend to do so, as these processes move forward.
	Clause 5 would oblige mortgage lenders to offer reasonable-rate loans for energy efficiency improvements. This is again very much in the spirit of what we are trying to do, but the noble Lord will have anticipated the reply that I have to give: it must be for lenders to decide on the products they offer to consumers. While we would encourage green products, we cannot force lenders in that way. However, we are supportive of all the initiatives to encourage energy conservation which are being taken by the lending industry. We are working with the industry to find ways of developing them further on the back of EPCs.
	I hope that the noble Lord feels that, although we cannot go all the way with him, we are certainly on the same journey in many ways. We have overtaken him slightly in some ways, too. It has been an important and interesting debate because it has raised the visibility and the profile of the issue as a whole. From around the House, unique contributions have been made, which show that essentially we are all committed to the same direction of travel. I look forward to the next stages of the Bill.